In the past few weeks pharmaceutical giant Johnson and Johnson were ordered in court to pay $572 million in damages to patients addicted to prescribed opiate drugs. This is a landmark case placing those companies producing painkillers at a similar level of responsibility as tobacco manufacturers. Worldwide it is estimated that 16 million people have at some point been addicted to opiates. These chemicals, which include morphine and heroin, are alkaloid chemicals found naturally in the opium poppy, Papaver somniferum. Our relationship with this plant is historic and complex. Its therapeutic benefits are without question, hence an opium poppy is seen on the emblem for Royal College of Emergency Medicine. Yet we have fought wars over control of opium and its role in society calls in question greater issues involving the role of prescribed drugs and the companies who produce them. To understand opium is to understand the history of our relationship with it.
Opium comes from the latex of the poppy. This is a sticky substance like sap which oozes out of the poppy if it is cut. We don’t know when we first realised the poppy’s potential but there is evidence of our Stone Age ancestors making it one of the first plants to be harvested. It’s easy to imagine one of our ancestors eating a poppy or licking the latex off their fingers and finding its hidden abilities. As a result of the poppy’s ability to nullify pain and bring on altered consciousness it became linked to deities throughout the ancient civilisations such as the Egyptians. For the ancient Greeks the poppy was a gift from the goddess Demeter and was associated with Hypnos, the god of sleep, and Morpheus, the god of dreams, whose name would give us ‘Morphine’. It’s at this point it is worth pointing out a difference in nomenclature. Drugs derived from opium are called opiates whilst synthetic drugs such as heroin are called opioids.
Opiates and opioids both work by acting on opiate receptors. When they bind to opiate receptors on neurons they cause a reduction in neurotransmitter release and so prevent signals being sent. There are four types of opiate receptor: mu, kappa, delta and nociceptin dotted throughout the body. As a result whilst opiates are excellent at dulling pain (analgesia) they also come with side effects as well as an impact on the chemistry of the brain. This brings addiction and dependence. This is the double edge sword of opium.
The eminent Basra physician al-Razi (854–925) is credited with being one of the first people to use opium as an anaesthetic. Yet the downsides of the poppy were soon becoming clear. The fourth ruler of the Mughal Empire, Jahangir (1569–1627) was so addicted to opium his wife ruled in his stead. It was written of the Turkish people that “there is no Turk who would not buy opium with his last penny.”
One of the most popular forms of opium, as both a medicine and a drug of abuse, is laudanum. The legendary English physician, Thomas Sydenham (1624–1689) to whom the expression ‘primum non nocere’ (first do no harm) has been credited, published his recipe in 1676. He wrote “among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.”
Laudanum was widely exhorted as a treatment for illnesses as wide ranging as coughs and pain. Despite its addictive tendencies it was a lot safer than many other treatments of the times which often contained poisonous heavy metals. And, due to the constipating side effects of opium, at a time of poor hygiene with diarrhoea common, it did offer some therapeutic benefit. Laudanum was a common base for most treatments at the time. In 1821 the essayist Thomas De Quincey (1785–1859) published Confessions of an Opium Eater, an autobiographical work chronicling his addiction to and misuse of opium.
One country which struggled in particular with addiction to opium was China, which sort to limit the influx of the drug. For the Imperial British, growing poppies in India, China was a convenient and hungry market and they defended that market violently. So the two Opium Wars were fought between 1839 and 1842 and then 1856 to 1860 between China and Britain, helped by the French for the second conflict. The resulting victories for Britain reduced China’s gross domestic product by a half, taking them from the largest economy in the world to diplomatic subservience, kept the opium flow in China open and started the process by which the British took hold of Hong Kong. The current political turmoil in Hong Kong, returned to China in 1997, can be led back to conflicts fought to ensure Chinese opium addicts were having their habits fed.
Around this time in Britain a chemist, Charles Romley Alder Wright (1844–1894), was seeking to overcome the problem of opium addiction by formulating a version of morphine with all of the analgesic benefits but which wasn’t addictive. He boiled morphine with a number of different acids. It’s fair to say he failed in his mission. He created diamorphine, otherwise known as heroin, an agent even more potent than heroin both in its analgesic and addictive properties. After Wright’s death the Bayer Laboratories in Germany took over production led by Heinrich Dreser (1860–1924). First sold as a cough suppressant, Bayer stopped manufacturing heroin in 1913 when it was clear how addictive their product was. It is around this time that other opiates were being created, such as codeine.
It was in China where opium dens were established. With economic migration of Chinese workers to the USA came these opium dens. Here users could smoke opium and receive a much faster and stronger hit than through eating opium. The rise of these dens was partially behind the US Chinese Exclusion Act of 1882 which sought to limit immigration from China. In 1906 the federal government under President Teddy Roosevelt passed the Pure Food and Drug Act, which required any “dangerous” or “addictive” drugs to appear on the label of products. Three years later, the Smoking Opium Exclusion Act banned the importation of opiates that were to be used purely for recreational use. This was also wrapped up in anti-Chinese sentiment rather than simple drug legislation.
After campaigning from the pathologist Hamilton Wright (1867–1917) who called opium “the most pernicious drug known to humanity” the Harrison Narcotics Tax Act of 1914 put taxes and restrictions on opium. Opium was stigmatised in the media and by officials. In the UK the supply of opium and its derivatives was controlled by pharmacists. The 1927 Rolleston Act gave prescribing power to doctors if they saw medical need. Addiction was seen as a medical need and so doctors were able to prescribe small amounts to try and wean their patients off the drugs. There was a clear division between the medical treatment of addicts and the criminal prosecution of producers and distributors. That changed in the 1960s.
In 1961 the Single Convention on Narcotic Drugs, an international treaty signed by all members of the United Nations, sought to restrict the spread of opium as well as other drugs. In the UK this led to the 1964 Drugs (Prevention of Misuse) Act which for the first time criminalised addiction. This created penalties for possession as well as stop and search powers for the police. The Misuse of Drugs Act 1971 divided drugs into categories A, B and C still in use today.
The debate about whether making criminals out of addicts actually works is ongoing and not something I’m going to dwell on much here. But it is true that the idea of illegal drugs with penalties for possession only dates back within a generation. A blink of an eye in relation to the millennia we’ve spent with opium. One country who took a very different approach is Portugal. At one point in the 1980s 1 in 10 Portuguese were addicted to heroin. The country had the highest rates of HIV infection in the European Union. In 2001 they decriminalised posssesion, users were instead directed to support and treatment, similar to practice in the UK before the 1960s. Since then, and not just due to the change in the law, deaths due to overdose, HIV transmission and drug related crime have all plummeted. This suggests an alternative approach to illegal opium. But it’s not just the illegal market we now face a challenge from.
Opiates and opioids remain our best analgesics for those with severe pain or at end of life. But all the evidence shows that they offer no benefit in long term use. The problem is in the UK chronic pain is on the rise. The British Pain Society estimates that as many as 28 million adults in Britain are living with pain lasting longer than 3 months. In giving his landmark judgement against Johnson & Johnson Oklahoma Judge Thad Balkman found the company guilty of:
“promotion of the concept that chronic pain was under-treated (creating a problem) and increased opioid prescribing was the solution.”
Similar claims have been made across the USA with more landmark trials expected. Chronic pain often has psychological issues attached to it. Yet in a short consultation with a GP or in a clinic there is rarely the opportunity to explore these. Opiates make a convenient solution. And so the double edge sword is wielded. Perhaps with litigation will come an open discussion about the use of opiates and the role of opium in our society. From a divine gift to a precious medical tool albeit one that needs to be used with caution.
Thanks for reading.
Originally published at https://mcdreeamiemusings.com on October 28, 2019.