Opioids Part III

By Frank G. Vice, DVM, BS Pharm

OpioidsDuring the late 19th to the middle 20th century, it has been estimated that 1 in 500 people were physically dependent on an opium based product. The reasons for opium use during this time period were related to medicinal and recreational uses, with a total lack of understanding about the physical dependency that opium use created.  The United States government was taxing opium importation and realized each time a heavier tax was levied, the illegal importation of opium increased and then decreased when the tax was lower.  In either case, opium continued to make its way into the hands of the user, becoming obvious, that tighter opium control was required. In 1914, the Harrison Narcotic Act was the most restrictive narcotic law in the land, establishing the legal term narcotic, along with stronger oversight of the manufacture and sale of habit forming drugs. It required all legal narcotic distributors, physicians, dentists, veterinarians, pharmacists, and other people involved in narcotic transactions, to register annually with the Treasury Department’s Bureau of Internal Revenue. Following annual registration, each registrant would receive a license, pay an annual narcotic tax, and keep records of the narcotic dispensed. The patent medicine industry was exempt from all of the requirements, provided they limited the amount of opium in each medicinal preparation. This law did not prevent narcotic use, nor did it make it illegal to be a drug addict.  It was simply an attempt to establish some opiate tax revenue and regulatory control. However, there was some confusion among physicians due to interpretation of the law by the Supreme Court. According to the Harrison Act, physicians, by law, had to stop writing narcotic prescriptions used as maintenance medications for their addicted patients. It was felt that it should be illegal for physicians to use maintenance drugs to support potential narcotic addicts since many patients had developed their addiction while being treated by physicians. The Harrison Act was mostly designed for regulation and control of narcotic traffic, thus making it impossible for addicts to legally maintain their habit.  It nearly shut down prescription narcotic use. However, illicit narcotic use and availability continued forcing users to support their habit through the illegal markets that were rapidly developing. By now, morphine had been chemically transformed into heroin, yielding a more potent chemical due to the lipid solubility which allowed a more rapid entry into the brain.

In an attempt to place tighter control over opium importation and illegal narcotic use, the United States government began enacting additional drug related legislation. In 1922, Congress passed the Jones-Miller Act in response to developing criminal activity and a related illegal drug market. This Act increased penalties for illegal narcotic possession and placed even stronger control on importation, drug smuggling and manufacturing, especially heroin, which was becoming a favorite drug. Government recognized that drug addiction, especially in federal prisons, was becoming a major problem. The Supreme Court, during the 1925 session, reversed itself, ruling that what was formerly called drug addiction was now an illness, thereby legally allowing physicians to write narcotic prescriptions as a part of the addiction maintenance program.  In 1928, most Americans felt that drug addicts should be gathered together, isolated, or segregated from the rest of society. Due to strong social and political pressure, government concluded that drug addicts were dangerous people with an illness, capable of criminal activity and spreading addiction. Therefore, responding to social pressure, Congress established two narcotic farms or hospitals designed to confine opium abusers in isolated facilities.  These hospitals were located in Lexington, Kentucky and Fort Worth, Texas, with each designed to isolate and segregate addicts for institutional treatment, being placed under restraint for a long periods of time.

In the early 20th century, it was felt that this type of restricted confinement would reduce the growth of drug addiction and eliminate the demand for smuggled narcotics. Much of society was frightened and considered drug addicts dangerous, capable of committing crime to support their habit. The Lexington farm opened in 1935 as a Public Health Service Hospital to monitor and treat approximately 1000 residents who were dependent on various types of drugs. This hospital ultimately evolved into a prison for drug addicts but closed in 1974 due to changing attitudes toward treatment options for addicted patients. Even though narcotic control laws continued to be passed by state and federal governments, much of the narcotics in 1935 were diverted into the war effort.  However, drug use continued to expand by way of smuggling throughout the criminal world.  Following WW ll, travel restrictions were lifted, allowing an expanded illegal narcotic transportation, which has increased each year. Even though the government had gone through multiple attempts to control the illegal use of narcotics, drug addiction remained a growing problem, supported by a criminal industry.  A separate Bureau of Narcotics was established to combat illegal narcotic trade by exerting more control over narcotic use. It was because of strong social pressure that Congress continued to pass legislation attempting to limit the on-going narcotic abuse problem.

In 1956, during the Eisenhower administration, Congress passed the Narcotic Drug Control Act which increased the mandatory minimum sentence resulting in jail time if violators were convicted of narcotic possession. Every year, with growing concern about the magnitude of narcotic addiction, each U.S. President pushed the fight in a war against drugs. The Kennedy administration in 1962 called for stricter federal control of habit forming prescription drugs and in 1968, the Johnson administration attempted more coordinated enforcement and narcotic control by merging all drug agencies into the justice department eventually to be called the Drug Enforcement Administration (DEA). Drug addict rehabilitation was attempted under the Rehabilitation Act, but this failed to accomplish the desired goals.  During this time, the Methadone Maintenance Program was developed using methadone through controlled dosing, helping to reduce narcotic withdrawal side effects in people trying to wean from narcotic abuse. Methadone was developed in 1937 as a pain killer to replace opium analgesia during the German war effort, but it was soon discovered that it helped with the transitional narcotic cravings during opiate withdrawal if used as a replacement therapy. During the latter part of the 20th century, methadone replacement therapy was the standard of care for opiate addiction. In 1969, the Comprehensive Drug Abuse Prevention and Control Act passed by Congress replaced all of the federal drug legislation since 1909. It was passed during the Nixon administration and legally placed habit forming drugs into five divided usage schedules according to their medical value, safety, and abuse potential with schedule l drugs, having no therapeutic medical benefit but the greatest abuse potential. The remaining abusive medications were placed into schedules ll thru V, with medications in these categories having therapeutic value but abuse potential. This federal legislation, which placed heroin in a schedule l category, remains the national drug policy today. It is a fact that drug addiction has continued as a medical problem and a social dilemma despite years of government oversight and regulatory control, and remains with no clear solution in site.

In today’s legal prescription use of opioids, physicians evaluate acute or chronic pain thresholds to determine the need for a scheduled narcotic. In recent years there has been a national escalation of prescription opiate abuse. These opiate medications include oxycodone (OxyContin, Percocet and Endocet) and hydrocodone (Norco, Vicodin and Lortab) along with fentanyl (Duragesic) patches).

It has been estimated that there was a national increase from 100 million narcotic prescriptions to 200 million narcotic prescriptions in the past two decades. This escalation of prescription narcotic use developed, in part, out of abuse and greed in the medical system, which directly involved Kentucky residents who were exploring every possible avenue to obtain enough opioids to maintain their abusive habit and sustain enough cash flow to buy more drugs. Along with this increase in prescription volume, there has been rampant addiction, overdoses, drug diversion, and death with data demonstrating prescription opioids and heroin are nearly equal as causative agents. These products were originally reserved for acute surgical or chronic cancer pain, but eventually grew into use for management of all types of chronic pain. According to new CDC (Center for Disease Control) recommended guidelines, opioids should be reserved for acute pain and avoided in use as first line chronic therapy. It was suggested that nonpharmacological interventions, physical therapy, exercise, and cognitive behavioral therapy, along with non-opioid drug options which include acetaminophen and nonsteroidal therapies, might offer benefits for patients in chronic pain. The CDC states there was no strong evidence for long term use for opioids in chronic pain management.

The author wishes to thank the following literary sources; “Drugs, Society and Human Behavior”, 2nd edition by Ray Oakley and; “Dark Paradise, A History of Opiate Addiction in America” by David T. Courtwright, and The Kentucky Pharmacist, “Understanding The Centers for Disease Control 2016 Guidelines on Management of Opioids for Chronic Pain”; by Vishal Patel Pharma D, January/February 2017

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