The problem with Opium

Opium Poppy Papaver

Somniferum Sleeping poppy Sedation Pain relief God’s own medicine Acts on brain’s

opiate receptor Endorphins

Endorphins

                           

Morphine

                    

Opium and its derivatives

raw opium extract

morphine codeine thebaine

Percadanheroin (1898)

Natural components (1800)

Routes of Administration

Upon until 1850 Smoking opium Landanum: opium dissolved into

spiced wine Often called opium eaters Really opium drinkers

Thomas DeQuincey

Confessions of an Opium Eater (1822)

“ I do not readily believe that any man, having once tasted the divine luxuries of opium will afterward descent to the gross and moral enjoyments of alcohol

I take it for granted that those eat now who never ate before and those who always ate now eat more”

Later volume, Miseries of Opium, detailing his agony of addiction not as widely remembered.

Samuel Taylor Coleridge English Poet 1772-1834 Kubla Khan written in landanum

dream In Xanadu did Kubla Khan

A stately pleasure-dome decree :Where Alph, the sacred river, ranThrough caverns measureless to manDown to a sunless sea.

Hector Berlioz French Composer 1803-1869 Symphonie Fantastique Program notes refer to artist

“poisoned with opium” who has visions, including:

March to the scaffold Dream of a witches' sabbath

American Civil War Hypodermic needle

came into use 1850 Morphine had been

extracted early 1800’s Thought no addiction

with injection because it bypassed stomach.

Soldier’s disease among veterans

Morphine as cure for alcoholism

Dr. Black (1889) “morphine calms in place of

exciting the baser passions, and hence is less productive of acts of violence and crime. In short, the use of morphine in place of alcohol is but a choice of evils, and, by far, the lesser.”

Patent Medicines

Lydia Pinkham’s Vegetable Compound

Most successful patent medicine of the 1800’s

“Female complaint” nostrum

15-20% alcohol and vegetable extracts

Sold until 1968

Many Patent Medicines:

Contained large amounts of alcohol (up to 47%)

Narcotics, such as morphine, cocaine, and opium

Caffeine Vegetable extracts

Journalists make an impact

Samuel Hopkins Adams. 1905. The Great American Fraud. Patent medicines attacked in a series of 11 articles in Collier’s magazine

Upton Sinclair. 1906. The Jungle. Book about the meat packing industry.

1906: Pure Food and Drug Act passed

Temperance movement

Concern about the impact of liquor on society

Pledge to give up: Hard spirits only Beer and Wine too Total temperance T totalers

Opium Den Drug laws 1870-1890 First anti-drug laws

passed in California eliminate opium dens of Chinese immigrants.

Connecticut law: addicts incompetent to handle personal affairs.

Harrison Narcotic Act Harrison Narcotic Act Tax act 1914 First national narcotic

act Trumped state laws Chief proponent was

William Jennings Bryan

Language of Harrison Act

“An act to provide for the registration of, and collection of internal revenue, and to impose a special tax upon all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute or give away opium or coca leaves, their derivatives or preparations, and other purposes.”

Physicians were concerned What about our ability to

write Rx for opiates? Many “medical addicts” Harrison Act: No problem Dr’s could register and

freely prescribe opiates as long as it was “in the course of his professional practice.”

Harry Anslinger Doctor’s rights didn’t

mean much to new head of the Bureau of Narcotics.

Part of Treasury Dept.

Started arresting and charging physicians

How could this be happening?

What is Addiction? Anslinger’s view was that addiction

was a moral weakness. Doctors are only enabling the

addiction. Doctors should be curing illness, not

perpetuating them. Addicts need to stop. Doctors arrested for writing

prescriptions

Behrman Case (1922) Prevented M.D.’s from

legally supplying drugs to addicts for self administration.

Addicts must be isolated and hospitalized.

Led to creation of Public Service Hospitals

Prohibition Volstead Act (1920) Non-medical use of

alcohol prohibited. Bootleggers Rum runners Organized crime

saw profit in distributing alcohol.

Repeal of Prohibition In 1933, FDR signed bill

repealing prohibition. Organized crime stops

distributing alcohol and switches to heroin (now the drug of choice)

Black market. Addiction becomes

centered in cities.

Public Service Hospitals Opening day at

hospital in Lexington, Kentucky (5/15/35)

Beginning of research on addiction.

NIDA’s roots

Success of the public hospitals

Most admissions were voluntary (75%). 70% of those left against medical advice. Others federal prisoners on drug charges. Treatment: detox and abstinence 90% of those who completed treatment

relapsed within a few years. Revolving door: addict detox, reduce

tolerance, restart habit when released.

Heroin problem gets worse Stronger laws More punishment Stop using 1951 Boggs Act set

minimum sentences

1956 Narcotic Drug Control Act made penalties stiffer.

Robinson vs California (1963)

Supreme Court finds that addiction is a disease.

Support from AA. Alcoholism began

to be seen as disease.

Heroin addiction not that different.

Narcotic Addict Rehabilitation Act

Congress passed act in 1966, following Supreme Court decision.

Sought to rehabilitate rather than imprison.

Short and long-term care. Develop new treatment programs. End dependence on addictive drugs End susceptibility to addiction

Comprehensive Drug Control Act 1970

Controlled substance act Five schedules, I – V More stringent regulations Penalties for possession and sale Moved from Treasury to Justice In 1988, cabinet level drug “czar”

To be continued

Treatment for heroin addiction

Heroin treatment In 1965, treatments

were still detox and abstinence.

Pubic Service Hospitals. Revolving door. Didn’t offer much hope. Relapse or death most

likely outcomes.

Therapeutic Communities Synanon most

famous. Founded by Chuck

Dedrich

Life in Synanon

Detox on your own. No medical help. Commit yourself to total abstinence Community would work on rebuilding

you. Start at lowest rung of social ladder. Move up a step as more trust in gained. Become a supervisor or mentor. Reenter society in stages.

Success of communities

Work well for those who stay in program. Most dropouts happened during the early

stages (50-90%). Begin to work outside, go to school. Many didn’t want to leave. Dependence transferred to the

community. A few communities turned into cults.

Daytop Village: success story Daytop is based on the

therapeutic community (TC) concept: a highly structured, family environment where positive peer interaction is emphasized. Separate and individualized programs are available for adolescents, adults, and all family members.

Limitations of TC’s

Not for everyone. Radical change in living

circumstances. Dropout rate high during early

stages. What if you had a large number of

people needing services? More rapid return to society.

Vietnam Veterans Vets served in area ready

access to heroin. Thousands were coming

back with addiction. 1970 alone, 100 O.D. deaths. 1971 VA set up 32 clinics

across the US to treat returning vets.

What would be the treatment?

Counter culture Another group of concern

were the hippies. Experimented with many

drugs, including Speed. Abbie Hoffman: “Speed

kills” Transition junkies turned

to heroin. Revolving door only path?

Enter Methadone

Methadone is a synthetic opiate Developed during the 1940’s Opiate agonist Fills the receptor sites. Takes the place of heroin. Eliminates drug hunger Prevents withdrawal.

New idea: Maintenance

Rather than detox and abstinence. Substitute methadone for heroin. Maintain the patient on methadone. When the time is right and patient is

ready, withdraw the methadone slowly.

No dramatic withdrawal. Eventually drug free.

Dole and Nyswander

First treatment program using using methadone maintenance

Advantage of Methadone

Legal and inexpensive Accurate dose and purity Reduce criminal activity Slower acting Last 24 hours Given oral dose in orange juice

Methadone as the “hook”

Get addicts into treatment Drug screenings Provide them with other services Job training Individual and family counseling Parenting skills “Focus and families” (video)

Success of methadone 70% of addicts who stayed in

the program stopped IV drug use

Reduction in drug related problems (80 to 25%)

Reduction in criminal activity (20 to 10%)

Slight increase is employment

Short comings of methadone

Moral question: not drug free Perpetuate addict mentality Substitute another drug or activity Methadone entering black market Attracts only 20% of addict

community

Other treatments Naltrexone Opiate antagonist Block effect of

opiates if taken Takes away the

high Reduces triggers Used for other

drugs and gambling

Harm Reduction

For those addicts who continue to use IV drugs, how can we make use safer?

Needle exchange programs Lower risk of infections: HIV Reduce the sharing of needles Make information available about

treatment, safe sex, etc.

What about heroin maintenance? Dutch, Swiss North America's first clinical trial of prescribed

heroin begins today VANCOUVER (February 9, 2005) – Enrolment begins here today in North America's first

clinical trial of prescribed heroin for people with chronic heroin addiction who have not been helped by available treatment options.

The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs.

Opium Trade Routes