DRUG EPIDEMIC S IN THE US – A Historical Perspective
by Susan Kim, Americorps VISTA at RxSafe Marin

The US is experiencing an Opioid Epidemic that is more harmful is a public health crisis. Drug overdose is the #1 cause of accidental death in America, surpassing car crashes and gunshots. Over 70,000 died from opioid ODs in 2018. Most U.S. drug epidemics over the past two centuries were sparked by pharmaceutical companies and physicians pushing products that gradually proved to be addictive and dangerous.

Beginning in the 1800s, opiate-based medications like opium was sold in liquid form like laudanum and used for pain or trouble sleeping. It was also used to get high by “opium fiends” who smoked it in opium dens in San Francisco’s Chinatown.

The drug problem shifted from opium after the Civil War when soldiers became addicted to a new pharmaceutical called morphine, one of the first of many man-made opioids. The morphine epidemic was made worse when pharmaceutical companies Merck & Bayer developed cocaine and heroin, in part to treat morphine addiction. Cocaine became an ingredient in over-the-counter tonics for sinus problems and other ailments. Because of its energizing effects, beverage makers put it in their wines and sodas and laborers sniffed it to get through grueling work shifts.

In the early 1900s, cocaine became a reviled epidemic and physicians began documenting use disorders and police linked cocaine use to prostitution and violent crime. Cocaine abuse led to the first national effort to contain a drug epidemic and in 1914, Congress passed the Harrison Act, making it illegal to sell cocaine and heroin in over-the-counter remedies or in consumer products. Cocaine use remained rampant in 1920s Hollywood, but the Depression and the growing stigma of cocaine use restrained the epidemic.

Amphetamines were developed in the 1930s and took off in the 1950s because they were marketed by drug companies and promoted by doctors for weight loss, anxiety and depression. The drug company, Burroughs Wellcome developed methamphetamine and marketed it to American housewives as a diet pill and energizer. Among other drug abusers, meth users were called speed freaks and were outcast in a society of drug-user outcasts. Greater regulation of the drugs in the 1970s along with the stigma attached to speed freaks, caused meth use to decline.

In the 1960s & 1970s, heroin-use surged again partly because soldiers returning from war who began using heroin in Vietnam but unlike previous drug epidemics fueled by doctors and pharmaceutical companies, the heroin crisis victimized poor inner-city neighborhoods most. In 1970-1971, more black and Puerto Rican youth died of heroin OD than any other cause but there was little compassion for heroin addicts. In 1971, President Nixon declared a “war on drugs”, kicking off a long period of fierce law enforcement and tougher sentences for drug crimes. Heroin use faded in the late ’70s but cocaine use came back stronger in the form of rock cocaine which sold on the streets for $5 or $10 fueling an epidemic of crack in the 1980s. At this time, youth were wary of heroin and needles, thought crack was less dangerous because it was smoked like marijuana. Like the heroin surge before it, crack was tied to urban blight and violent crime and died out in the 1990s.

The US history of drug epidemics have experts examining solutions from a historical perspective. Evidence had determined that it was not the strict police action towards drug users and dealers that curbed the crack crisis. Instead, the decline of crack-use is attributed to families and communities who were shattered by crack-related murders and arrests, causing a growing repulsion to crack and “crackheads” in the community.

In 1900, when cocaine and heroin were legal and popular, there were 250,000 Americans with drug addiction, according to one historical estimate. That was about 1 in 300 Americans. Today, the estimate is 1 in 133, and the drugs they use are deadlier than ever. There were fewer than 3,000 overdose deaths in 1970 during the heroin epidemic that was raging in U.S. cities. There were fewer than 5,000 recorded in 1988, around the height of the crack epidemic. In 2018, more than 70,000 Americans died from an opioid drug overdose. That’s a huge increase compared to the past U.S. drug epidemics. OxyContin and aggressive marketing and distribution pushed hundreds of millions of pills into communities. Then more and more addicts turned to cheaper alternatives, bought illegally, like heroin and fentanyl.

SOLUTIONS – What to do now?
The first step in understanding substance use disorder is to ask what is stigma? Stigma, by definition, is a mark of disgrace associated with a circumstance, quality, or person. Essentially, a stigma is a bad reputation across a specific group of people. The stigma of addiction comes as no surprise considering so few people understand the disease of addiction at all. Science has proven that substance use disorder is a chronic relapsing brain disease that can be managed with medical treatment. It is NOT a moral failing or a character flaw.  Addiction is highly stigmatized, and that stigma is fueling an American public health crisis.

The World Health Organization (WHO) defines stigma as a major cause of discrimination and exclusion and it contributes to the abuse of human rights. Stigma is rarely based on facts but rather on assumptions, preconceptions, and generalizations. Its negative impact can be prevented or lessened through education and awareness. This is the time for change.

Many other diseases like Cancer and HIV, have been harmfully affected by stigma. Years ago, people whispered about “The Big C”.  It was taboo, and people who had cancer were often isolated but as people began talking about cancer openly, sharing their personal stories and uniting their communities, the stigma subsided. Today, cancer awareness events and organizations commonplace making people unaware that the disease was considered a shameful secret

For centuries, those who indulged in excess were judged, and excessive use was the moral failure of the individual. In the 1970s, drug policies centered on punishment and those who used drugs were criminals who made a personal choice to break the law. It was the moral theory of addiction.

Then In the 1980s, the disease model was popularized, viewing addiction as a biological disease that could be treated like other medical diagnoses. In this model, people began to understand that addiction is something that happens in the brain, and overcoming it requires medical treatment.

At the same time addiction was being defined as a brain disease, another movement called Co Addiction or “tough love” became popular.  The co-dependency movement stated that addicts need to hit “rock bottom” before they can turn their life around. “Tough love” makes sense if one considers addiction as a choice. Setting limits hoping to force an individual to choose to stop being an addict. This approach causes pain to those families involved, and for some “tough love” has worked.  It is understandable why a family uses the “tough love” approach. Families feel they have no more options because substance use disorders (SUD) affects not only the user but everyone close to them. Families coping with SUD are repeatedly feeling frustrated, scared and hopeless and these feelings take their toll, leaving all lost and not knowing what to do. “Tough love” feels like the last stop of a complicated journey but unfortunately, it also removes the love and support that people with SUD desperately need. They already feel stigmatized and isolated, alone and unworthy, negative feelings, for which drug use acts as a coping mechanism. Depriving someone struggling with SUD of support and love often amplifies those negative feelings of loneliness, fear or anger resulting in the opposite of what was intended: increasing drug use, not deterring. On the other hand, providing love, empathy, and social support to SUD sufferers have been shown to have a greater positive impact on recovery than “tough love.” Allowing someone to “hit rock bottom” can result in worse outcomes, possibly even death, as “rock bottom” may mean an overdose from which they cannot recover.

Stigma is preventing harm reduction practices. Narcan and fentanyl test strips save lives. The rates for new HEP A, B & C, and HIV cases are the highest ever. In one small city of 50,000, 70 new cases of HIV were reported over a 4-month period.  Syringe exchange can stop the spread of HEP A, B & C, and HIV. That’s what harm reduction is all about. It prevents an already bad situation from getting worse.

Health officials are fighting the current opioid epidemic on three fronts, preventing opioid OD deaths, helping people recover from addiction, and preventing new cases of substance use disorders. By studying the history of drug epidemics in the US, experts now know what doesn’t work. Today, many including law enforcement believe the “war on drugs” is ineffective in the fight against drug epidemics. Data indicates that incarceration drug users serve to add to the problem. Society is beginning to understand that we cannot arrest our way out of the opioid crisis. Health officials recommend prevention and stigma awareness education & reduction as the best tools to combat substance use disorders. Co-dependency movements like “tough love” ostracize and isolate people who are already suffering and does little to help them. Stigma is the biggest barrier to recovery and may impede them from seeking treatment.

Society needs to support people and families suffering from substance use disorder better. The first step is to address the stigma of addiction and open our hearts and minds to new treatment tools and tactics. Recognize that MAT (Medically Assisted Treatment) or MOUD (Medication for Opioid Use Disorder) plus behavioral therapy is the best treatment and allows MAT / MPUD in jail. All Americans need to support harm reduction like Narcan training & distribution, syringe exchange, and support data-proven methods and tools like MAT and MOUD.

Dr. Kimberly Sue is the medical director of the Harm Reduction Coalition, a national advocacy group that works to change U.S. policies and attitudes about the treatment of drug users. She’s also a Harvard-trained anthropologist and a physician at the Rikers Island jail system in New York.

The idea that substance use is a disease of the will is very heavily entrenched in American ideology. We have a hatred of people who are dependent on anything — including the government — for support. The idea of people being on welfare, the idea of people not working. We have these very strong puritanical roots and the idea that we make our bed, we lie in it, and you pull yourself up by your own bootstraps. It pits people against each other in a way.

People who use drugs — they have a physical dependence on a substance. It doesn’t necessarily mean that they’re bad people, but our society tells them that they’re bad people.

Sue thinks it’s a huge mistake to put people with drug use disorder behind bars. “Incarceration is not an effective social policy,” she says. “It’s not an evidence-based policy. It’s not effective in deterring crime. But we continue to rely on it for reasons that have to do with morality.”

Click the link to read more about addiction from an anthropological viewpoint, Opioid Addiction: An Anthropologist’s Perspective by Dr. Kimberly Sue.