A Deep Dive Into the Opioid Crisis

Editor’s note: the following is the first essay in a series, written by former Moscow Times co-worker and current E.R. doctor Matt Bivens. The remaining features will be published serially on his Substack site, 

The 100 Days

. None of the articles in the series will be paywalled. In a normal presidential election year, the opiate addiction crisis would be a front-and-center domestic issue, but for a variety of mostly illegitimate reasons, it flies somewhat under the radar. Matt’s series chronicles the surprising and little-understood reasons contributing to this man-made, rapidly worsening disaster.

Yes, we in the medical profession got millions of Americans addicted to heroin and fentanyl. But that was all just a big misunderstanding. Why get into it? The Economics of Prohi... Thornton, Mark Best Price: $7.33 Buy New $1.99 (as of 06:55 UTC - Details)

And sure, nearly one in ten adults has had a family member die from a drug overdose. Ordinary people are furious about it, too. Their under-appreciated rage drove skepticism of official COVID-19 narratives, and that same rage might sway the outcome of the Presidential election — heck, might even land us in a war with Mexico! (Wouldn’t that be the ultimate “Wag the Dog”-level distraction from those sociopaths upstairs in our House of Medicine!)

So, yes, agreed. All good points.

We medical people who see the patients and do all of the work — we, the house staff — we’re downstairs people. We can’t do anything about what goes on above. Agreed, it’s shameful how easily the upstairs sociopaths conned us, and it’s annoying to see them now so fabulously rich. But doctors being intentionally manipulated into destroying the lives of millions — that could have happened to anyone. Why stay angry about it? Ancient history! It’s not like it’s still happening, right? (Right?)

Surely you don’t want to burn down the entire house? We work here. And the pay is not bad. Let’s just focus on the patients before us, and try to stay positive. Right?

Heroin™ — brought to you by Bayer!

As a medical student, I was once told by my attending physician that people treated with morphine for pain don’t get addicted.

Surprised, I asked, “But what about all the Civil War veterans?”

When the U.S. Civil War ended in 1865, both sides demobilized a weary horde of chronically ill and wounded. Some soldiers had contracted tuberculosis, or a lingering pneumonia (in the days before antibiotics). Others had suffered field amputations with handheld saws. But whether the question was chronic coughing or terrible pain, the answer was morphine. The newly invented hypodermic needle allowed for fast-acting injections. Veterans everywhere got hooked, to the point where addiction was called “the Soldier’s Disease.” Soon morphine moved beyond the battlefield and was in use for everything from menstrual cramps to teething.

Things got so bad that when heroin (diacetylmorphine) arrived, it was welcomed as an improvement. Chemists had discovered it decades earlier, but in 1898 the pharmaceutical company Bayer started selling it as Heroisch, German for “heroic.”

Heroin was a trade name. It was Heroin™ — brought to you by Bayer! 

Doctors desperate for something safer than morphine often convinced themselves this new drug wasn’t addictive.

“Heroin… possesses many advantages over morphine,” wrote a physician in 1900, in the precursor to the New England Journal of Medicine. “It is not a hypnotic… [and there is no] danger of acquiring the habit.” The philanthropic St. James Society even mounted a campaign to mail free heroin samples to morphine addicts (!), to help them break the habit.

Other doctors saw the public swilling down heroin and berated their fellow physicians for not sounding the alarm.

“The patient comes to look on heroin as a harmless sedative for his cough,” wrote one such physician in 1912, in the Journal of the American Medical Association, because too many doctors think it’s safe:

“A patient who came under my observation told a physician, who was called to treat him for an attack of laryngitis, not to give him anything that contained opium, because he had formerly been a slave to this drug. The physician replied: ‘I will give you some heroin; there is no danger of habit from that’.”

Ordinary Americans weren’t buying it, and by 1906 we had established the federal Food & Drug Administration, because moms want to know if it’s got heroin. Cure-alls like the morphine-and-alcohol-based Mrs. Winslow’s Soothing Syrup definitely did quiet fussy babies, but it’s believed thousands never woke up again.

President Teddy Roosevelt appointed an “Opium Commissioner,” who looked around and saw track marks on the arms of everyone from aging Army of the Potomac vets to high society ladies, and declared, “Americans have become the greatest drug fiends in the world.” It was our first Opioid Crisis. It had been driven by genuine ignorance and a lack of good alternatives — but tellingly, also by the inappropriate use of heavily marketed and physician-endorsed treatments. In response, the nation went on a scorched-earth campaign against all addictive substances, starting with new anti-narcotics agencies staffed by G-men in trench coats, and culminating in the U.S. Constitutional amendment to ban alcohol. Again: We rewrote the Constitution to outlaw alcohol. That we once went so far suggests how bad things had gotten.

This all seems like a glaringly obvious cautionary tale for the House of Medicine. Yet somehow, not 70 years after the nation had walked away from the Prohibition experiment, medical schools — medical schools! — were abruptly teaching that opioids weren’t necessarily addictive. How Not to Die: Discov... Stone, Gene Best Price: $8.10 Buy New $14.52 (as of 05:53 UTC - Details)

When my attending said a patient wouldn’t get addicted if a doctor gave morphine for pain, he was simply channeling what all the best people were saying. For example, in 2000, the Joint Commission — an independent non-profit that sets accreditation standards for hospitals — published a book for physician education that claimed:

There is no evidence that addiction is a significant issue when persons are given opioids for pain control.

No evidence. And if the medical students ask about morphine-enslaved Civil War veterans? The Joint Commission’s book dismisses such concerns as “inaccurate and exaggerated.”

It was the same over at the Federation of State Medical Boards — a trade organization for the bodies in each state that license, investigate and discipline doctors. A set of FSMB guidelines from this era sternly stated that opioids are “essential” for treating various kinds of pain, and only mentioned addiction to warn that “inadequate understandings” of that could lead to “inadequate pain control.”

I was literally told by my attending — who was just echoing those who accredit the hospitals and license the doctors — to “do more reading.” That’s a common directive to a medical student: Stop with the skeptical questions and go study.

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