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Morphine
Since prehistoric times, opium was extracted from the poppy flower for medicinal and recreational use [1]. German chemist Friedrich Serturner first isolated morphine, the most active component in opium [1]. He named the drug after the Greek god of dreams, Morpheus [1]. Image Attribution: "Friedrich Wilhelm Adam Sertuerner" by Julius Giere is licensed under PD-old -
The Rise of Morphine
Morphine became the mainstay pain treatment in the United States (U.S.), especially for injured soldiers during the Civil War [2]. Morphine addiction became prevalent in the post-war era [2]. Image Attribution: "Kurz and Allison - Battle of Franklin, November 30, 1864" by Kurz and Allison and Restoration by Adam Cuerden is in the public domain in the United States because it was published (or registered with the U.S. Copyright Office) before January 1, 1923. -
Heroin
Due to morphine’s side effects, scientists sought a less addictive alternative. German pharmaceutical company Bayer championed heroin as a "non-addictive" morphine substitute and children's cough suppressant [2]. In the U.S., the philanthropic Saint James Society even mounted a campaign to supply free heroin samples to morphine addicts [3]. Image Attribution: "Bayer Heroin bottle" by Mpv_51 has been released into the public domain by its author. -
Harrison Narcotics Tax Act
Heroin addiction rose to such alarming rates in the U.S. that the government made initial efforts to regulate the distribution and sale of medical opium-based drugs through the Harrison Narcotics Tax Act [2]. The act intended to prevent doctors from prescribing opiates to heroin users to “maintain their habit.” [4] -
Heroin Act
Regulation escalated to prohibition when Congress passed the Heroin Act to make heroin illegal in the U.S [3]. Without physicians as a legal source of heroin, the illicit drug market flourished [5]. -
The 1940s World War II
Opium trade routes were blocked during World War II, and the lack of available opioids essentially eliminated opioid addiction in the U.S. until after the war [4]. Image Attribution: "450223-M-0000R-001" by Joe Rosenthal is considered public domain and has been cleared for release. -
Methadone
It is believed that during World War II, low morphine supplies drove German scientists at IG Farben to develop methadone, a long-acting synthetic opioid [5]. More likely, they discovered the compound unexpectedly, and methadone was not initially utilized due to numerous side-effects [5]. Later in 1947, the pharmaceutical company Eli Lilly introduced methadone as an analgesic in the U.S. Image Attribution: "Prescription Drug Overdoses-CDC Vital Signs" by the CDC is in the public domain. -
Methadone Maintenance Treatment
Dr. Vincent Dole showed that longer-acting oral methadone could prevent opioid abstinence symptoms [5]. He thus developed a methadone maintenance treatment (MMT) regime for patients suffering from opioid abuse. Before MMT, physicians remained withdrawn from treating addiction due to severe prohibition legislation [5]. Concerns about methadone abuse, however, led to strict government regulation of the drug. -
The War on Drugs
In response to the growing heroin epidemic in the U.S., President Richard Nixon declared War on Drugs. Nixon called drug abuse “public enemy #1” due to research at the time revealing a link between drug addiction and crime [6]. Previously, local agencies enforced illicit drug laws. Starting with the Nixon administration, the federal government became heavily involved. Image Attribution: "Richard Nixon 09 Jul 1972" by the United States Federal Government is in the public domain. -
The 1980s Opiophobia
Many physicians developed "opiophobia," a fear of prescribing opioids, resulting in under-treatment of pain [7]. -
The Fifth Vital Sign
Clinicians and pain societies lobbied to expand opioid medication for pain management. The medical landscape shifted to incorporate pain as the “fifth vital sign.” [7] Pharmaceutical companies developed and hailed new opioid formulations with “extended release technology” as less addictive. Aggressive marketing compelled physicians to issue more medical prescriptions, resulting in “opiophilia,” or overprescribing of opioids [7]. -
Oxycontin
Purdue Pharma promoted OxyContin as a controlled-release formulation that would prevent abuse [4]. OxyContin proved easy to abuse by crushing, snorting, and injecting the pills. Image Attribution: "OxyContin setup" by 51fifty is licensed under CC BY-SA 3.0 -
Buprenorphine
The FDA approved the use of buprenorphine to treat opioid addiction. A partial agonist, buprenorphine is weaker than other opioids and its opioid effects level off after a certain dosage [8]. Buprenorphine’s “ceiling effect” thus reduces the risk of abuse compared to full opioid agonists [8]. In contrast to methadone, any trained physician can prescribe and dispense buprenorphine. Image Attribution: "Buprenorphine naloxone Tablets Bottle" by Tmeers91 is licensed under CC BY-SA 3.0. -
Fentanyl
Fentanyl is a synthetic opioid that can be administered noninvasively through patches and lollipops. Fentanyl’s commercial success drove pharmaceutical companies to search for more rapid-onset delivery systems [9]. In 2006, the company Cephalon created Fentora, a sugar-free buccal tablet that releases fentanyl into the bloodstream even more effectively than lozenge preparations [9]. Image Attribution: "Fentanyl lollipops Actiq 400 mcg" by Crohnie is licensed under CC BY-SA 3.0. -
The Influx of Fentanyl
Illicit drug markets began to sell heroin laced with illegally manufactured fentanyl, sometimes unbeknownst to the users [10].This mixture is dangerous because fentanyl is more potent than heroin and leads to overdose at a much lower dosage. -
The Current Opioid Crisis
Between 2000-2016, overdose deaths due to prescription and illicit opioids increased over 200% [11]. Fentanyl became the most common opioid responsible for fatal overdoses [10]. The alarming rate of opioid deaths prompted the FDA to declare the Opioid Epidemic its most significant health crisis. Image Attribution: "U.S. Department of Agriculture Follow
Pills and a needle" by USDA is in the public domain.
