The man was bleeding, wounded in a bar fight, half-conscious. Charles Schuppert, a New Orleans surgeon, was summoned to help. It was the late 1870s, and Schuppert, like thousands of American doctors of his era, turned to the most effective drug in his kit. “I gave him an injection of morphine subcutaneously of ½ grain,” Schuppert wrote in his casebook. “This acted like a charm, as he came to in a minute from the stupor he was in and rested very easily.”
Physicians like Schuppert used morphine as a new-fangled wonder drug. Injected with a hypodermic syringe, the medication relieved pain, asthma, headaches, alcoholics’ delirium tremens, gastrointestinal diseases and menstrual cramps. “Doctors were really impressed by the speedy results they got,” says David T. Courtwright, author of Dark Paradise: A History of Opiate Addiction in America. “It’s almost as if someone had handed them a magic wand.”
By 1895, morphine and opium powders, like OxyContin and other prescription opioids today, had led to an addiction epidemic that affected roughly 1 in 200 Americans. Before 1900, the typical opiate addict in America was an upper-class or middle-class white woman. Today, doctors are re-learning lessons their predecessors learned more than a lifetime ago.
Opium’s history in the United States is as old as the nation itself. During the American Revolution, the Continental and British armies used opium to treat sick and wounded soldiers. Benjamin Franklin took opium late in life to cope with severe pain from a bladder stone. A doctor gave laudanum, a tincture of opium mixed with alcohol, to Alexander Hamilton after his fatal duel with Aaron Burr.
The Civil War helped set off America’s opiate epidemic. The Union Army alone issued nearly 10 million opium pills to its soldiers, plus 2.8 million ounces of opium powders and tinctures. An unknown number of soldiers returned home addicted, or with war wounds that opium relieved. “Even if a disabled soldier survived the war without becoming addicted, there was a good chance he would later meet up with a hypodermic-wielding physician,” Courtright wrote. The hypodermic syringe, introduced to the United States in 1856 and widely used to deliver morphine by the 1870s, played an even greater role, argued Courtwright in Dark Paradise. “Though it could cure little, it could relieve anything,” he wrote. “Doctors and patients alike were tempted to overuse.”
Opiates made up 15 percent of all prescriptions dispensed in Boston in 1888, according to a survey of the city’s drug stores. “In 1890, opiates were sold in an unregulated medical marketplace,” wrote Caroline Jean Acker in her 2002 book, Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control. “Physicians prescribed them for a wide range of indications, and pharmacists sold them to individuals medicating themselves for physical and mental discomforts.”
Male doctors turned to morphine to relieve many female patients’ menstrual cramps, “diseases of a nervous character,” and even morning sickness. Overuse led to addiction. By the late 1800s, women made up more than 60 percent of opium addicts. “Uterine and ovarian complications cause more ladies to fall into the [opium] habit, than all other diseases combined,” wrote Dr. Frederick Heman Hubbard in his 1881 book, The Opium Habit and Alcoholism.
Throughout the 1870s and 1880s, medical journals filled with warnings about the danger of morphine addiction. But many doctors were slow to heed them, because of inadequate medical education and a shortage of other treatments. “In the 19th century, when a physician decided to recommend or prescribe an opiate for a patient, the physician did not have a lot of alternatives,” said Courtwright in a recent interview. Financial pressures mattered too: demand for morphine from well-off patients, competition from other doctors and pharmacies willing to supply narcotics.
Only around 1895, at the peak of the epidemic, did doctors begin to slow and reverse the overuse of opiates. Advances in medicine and public health played a role: acceptance of the germ theory of disease, vaccines, x-rays, and the debut of new pain relievers, such as aspirin in 1899. Better sanitation meant fewer patients contracting dysentery or other gastrointestinal diseases, then turning to opiates for their constipating and pain-relieving effects.
Educating doctors was key to fighting the epidemic. Medical instructors and textbooks from the 1890s regularly delivered strong warnings against overusing opium. “By the late 19th century, [if] you pick up a medical journal about morphine addiction,” says Courtwright, “you’ll very commonly encounter a sentence like this: ‘Doctors who resort too quickly to the needle are lazy, they’re incompetent, they’re poorly trained, they’re behind the times.’” New regulations also helped: state laws passed between 1895 and 1915 restricted the sale of opiates to patients with a valid prescription, ending their availability as over-the-counter drugs.
As doctors led fewer patients to addiction, another kind of user emerged as the new face of the addict. Opium smoking spread across the United States from the 1870s into the 1910s, with Chinese immigrants operating opium dens in most major cities and Western towns. They attracted both indentured Chinese immigrant workers and white Americans, especially “lower-class urban males, often neophyte members of the underworld,” according to Dark Paradise. “It’s a poor town now-a-days that has not a Chinese laundry,” a white opium-smoker said in 1883, “and nearly every one of these has its layout” – an opium pipe and accessories.
That shift created a political opening for prohibition. “In the late 19th century, as long as the most common kind of narcotic addict was a sick old lady, a morphine or opium user, people weren’t really interested in throwing them in jail,” Courtwright says. “That was a bad problem, that was a scandal, but it wasn’t a crime.”
That changed in the 1910s and 1920s, he says. “When the typical drug user was a young tough on a street corner, hanging out with his friends and snorting heroin, that’s a very different and less sympathetic picture of narcotic addiction.”
The federal government’s efforts to ban opium grew out of its new colonialist ambitions in the Pacific. The Philippines were then a territory under American control, and the opium trade there raised significant concerns. President Theodore Roosevelt called for an international opium commission to meet in Shanghai at the urging of alarmed American missionaries stationed in the region. “U.S. delegates,” wrote Acker in Creating the American Junkie, “were in a poor position to advocate reform elsewhere when their own country lack national legislation regulating the opium trade.” Secretary of State Elihu Root submitted a draft bill to Congress that would ban the import of opium prepared for smoking and punish possession of it with up to two years in prison. “Since smoking opium was identified with Chinese, gamblers, and prostitutes,” Courtwright wrote, “little opposition was anticipated.”
The law, passed in February 1909, limited supply and drove prices up. One New York City addict interviewed for a study quoted in Acker’s book said the price of “a can of hop” jumped from $4 to $50. That pushed addicts toward more potent opiates, especially morphine and heroin.
The subsequent Harrison Narcotic Act of 1914, originally intended as a regulation of medical opium, became a near-prohibition. President Woodrow Wilson’s Treasury Department used the act to stamp out many doctors’ practice of prescribing opiates to “maintain” an addict’s habit. After the U.S. Supreme Court endorsed this interpretation of the law in 1919, cities across the nation opened narcotic clinics for the addicted – a precursor to modern methadone treatment. The clinics were short-lived; the Treasury Department’s Narcotic Division succeeded in closing nearly all of them by 1921. But those that focused on long-term maintenance and older, sicker addicts – such as Dr. Willis Butler’s clinic in Shreveport, Louisiana – showed good results, says Courtwright. “One of the lessons of the 20th-century treatment saga,” he says, “is that long term maintenance can work, and work very well, for some patients.”
Courtwright, a history professor at the University of North Florida, wrote Dark Paradise in 1982, then updated it in 2001 to include post-World War II heroin addiction and the Reagan-era war on drugs. Since then, he’s been thinking a lot about the similarities and differences between America’s two major opiate epidemics, 120 years apart. Modern doctors have a lot more treatment options than their 19th-century counterparts, he says, but they experienced a much more organized commercial campaign that pressed them to prescribe new opioids such as OxyContin. “The wave of medical opiate addiction in the 19th century was more accidental,” says Courtwright. “In the late 20th and early 21st centuries, there’s more of a sinister commercial element to it.”
In 1982, Courtwright wrote, “What we think about addiction very much depends on who is addicted.” That holds true today, he says. “You don’t see a lot of people advocating a 1980s-style draconian drug policy with mandatory minimum sentences in response to this epidemic,” he says.
Class and race play a role in that, he acknowledges. “A lot of new addicts are small-town white Americans: football players who get their knees messed up in high school or college, older people who have a variety of chronic degenerative diseases.” Reversing the trend of 100 years ago, drug policy is turning less punitive as addiction spreads among middle-class, white Americans.
Now, Courtwright says, the country may be heading toward a wiser policy that blends drug interdiction with treatment and preventive education. “An effective drug policy is concerned with both supply reduction and demand reduction,” he says. “If you can make it more difficult and expensive to get supply, at the same time that you make treatment on demand available to people, then that’s a good strategy.”