History of Opioid Use in the United States

In the late 1700’s an opium extract called Laudanum, which contained alcohol, and Black Drop Opium were common. These were used to treat stomach ailments and for a calming effect.

In the early 1800’s, medicines with tincture of opium were available from apothecaries and door to door peddlers. It was sold freely and was inexpensive. Society accepted the use and dependency that developed as a medical treatment. In 1832, advances in technology led to the commercial production of morphine. This was followed shortly after by the invention of the hypodermic syringe. During the Civil War in the 1860’s, morphine was used to treat the injuries. In the years to follow, morphine was used to treat their chronic pain, as well as the dependency that they developed, which was called “Soldier’s Disease”. The war was followed by a surge in immigration of Chinese laborers, and an increase in opium abuse. This led to the “Temperance Movement”, and a concern of a dangerous, foreign made problem. By the 1890’s, society had shifted its view to a criminal justice model to control the abuse of opioids. But throughout the 1800’s there was no control or restriction of the import or use of opium or opiate products. In 1898, a process was discovered to convert morphine into heroin, and it became commercially available. A large underground black market to heroin soon developed.

By 1900, there were an estimated 250,000 opiate addicts in the United States. Patients seeking medical treatment began to shift from physician’s offices to “morphine clinics”, where groups of addicts were given daily morphine injections. These were increasingly run by police, reflecting society’s growing view that addiction was a criminal justice concern. In 1909, the smoking of opium was outlawed. And in 1914, there was another dramatic change in the treatment of addiction with the Harrison Act. This made it illegal to prescribe opioids, like morphine for the maintenance or treatment of addiction. The “morphine clinics” were closed, and the effort to control addiction further shifted to the criminal justice system.

Throughout the 1900’s, and especially after the battles of World War I, World War II, and the Vietnam War, the use of heroin surged and there were an estimated 1 million active heroin users. After years of research in 1965, Vincent Dole and his wife Marie Nyswander, published a landmark paper on the effectiveness of methadone maintenance, and the importance of counseling and other social support services. In 1972, methadone maintenance treatment for addiction was legalized. It was estimated that if a patient participated in treatment for 9-18 months, about 80% achieved long term recovery. Then in 1996, Purdue Pharma introduced Oxycontin, a very potent, 12 hour long acting formulation of oxycodone, so patients could control their pain through the night. Legitimate patients prescribed the new drug became dependent, and abusers soon began to crush, snort and inject the med, and addiction and overdose deaths rates surged.

By 2000, SAMHSA (the Substance Abuse Mental Health Service Administration) estimated that 2.5 million people were abusing opioid meds like Oxycontin, Vicodin, and Percocet. The focus had now changed from heroin to the opioid medications. In 2007, a SAMHSA study reported that 55% of people age 12 or older who abused pain relievers, got their drugs free from friends or relatives. Another 14% bought them from friends or relatives, 19% got them from one physician, and less than 4% purchased them from a dealer or stranger. And it estimated that approximately 22 million people were dependent or abusing opioids, with only 2.4 million of those people were receiving addiction treatment. Methadone treatment was very strict in its early requirements, and did not appeal to opioid and heroin users, so an effort was made to find a safer, more effective alternative treatment. The new goal was to transition the treatment of addiction back to the medical treatment model from the criminal justice system, and also transition care to a long-term treatment model rather than repeated short term detox stays. In order to implement this change, an amendment was passed called the Drug Addiction Treatment Act of 2000 (DATA 2000). This authorized qualified physicians to prescribe approved medications for the maintenance and detox treatment of opioid dependence. And in 2002, the FDA approved the use of Buprenorphine for the treatment of opioid dependence in an office-based setting. This is currently the only drug approved under DATA 2000 for this use.

Qualified physicians had to have specific training to be certified in addiction medicine, and were limited to treatment of 30 patients the first year, and then 100 patients thereafter. That number has now increased to 275 patients with certain requirements. In 2004, SAMHSA published clinical guidance materials called “Treatment Improvement Protocols (TIP) for prescribing Buprenorphine. And the Physician Clinical Support System (PCSS) was organized whereby physicians may be teamed up with an expert mentor for consultation. In 2010, SAMHSA completed a DATA follow up report noting that 1-2 million patients have been treated with Buprenorphine. 31% were new to any type of substance abuse treatment, and 60% were new to medication-assisted treatment (MAT). They also found that only 9% transferred from methadone to Buprenorphine treatment, and 60% of Buprenorphine patients were addicted to non-heroin opioids, a population that had generally avoided methadone treatment in the past. A study by Sullivan et al noted that “although the abuse of both heroin and opioid pharmaceuticals continues to be a significant problem, office-based buprenorphine treatment has proven to be an effective public health approach to containing the epidemic”. And that “large numbers of addicts have found life-saving treatment and have been able to become functioning and contributing members of society. For the first time, an effective medical treatment has had a significant impact on this chronic public health problem”.