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  In 1914, the United States Congress passed the Harrison Act, forcing doctors to register and maintain records of all narcotic prescriptions. (In addition to relieving pain, opium is a narcotic, a word derived from the Greek narkoun, meaning “to make numb.” All narcotics, by definition, suppress the central nervous system, causing drowsiness, stupor, and occasionally coma.) In 1919, the U.S. Supreme Court extended the act, making it clear that doctors were prohibited from prescribing narcotics to maintain an addiction. Almost a hundred years would pass before doctors were held accountable for violating this law.

  Opium was now restricted by state legislatures and reviled by the American public. But the enslavement of Americans by opium and its derivatives was just getting started.

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  ALTHOUGH OPIUM WAS CLEARLY addictive to individuals and destructive to society, its pain-relieving properties were undeniable. No other drug could match it. Scientists were desperate to find a way to retain opium’s analgesic properties while jettisoning its addictive properties. In the early 1800s, a young German chemist became the first to try.

  In 1803, Friedrich Sertürner, a 20-year-old chemist’s apprentice, isolated opium’s most abundant and most active ingredient. He named it morphium after the Greek god of dreams: Morpheus. Later, the name was changed to morphine. Sertürner never trained at a university, never earned a degree, had no professional standing, made his own laboratory equipment, and tested the effects of his newfound product on the only person he could find to do it: himself. A shy and solitary man, this remarkably young chemist’s apprentice would soon change the face of medicine.

  Sertürner found that morphine was about six times more powerful than opium, causing almost immediate euphoria followed by depression and dependence. When he finished his studies, he was addicted to the drug. Worried that he had created a monster, Sertürner warned, “I consider it my duty to attract attention to the terrible effects of this new substance I called morphium in order that calamity may be averted.” Sertürner’s warning went unheard. By 1827, the German pharmaceutical company Merck began mass-producing the drug. European doctors soon prescribed morphine for a variety of illnesses, including alcoholism, inadvertently shifting the addiction from alcohol to morphine.

  Then a medical invention changed the face of narcotic addiction.

  In 1853, a doctor in Edinburgh, Scotland, named Alexander Wood attached a syringe to a needle, allowing morphine to be injected directly into the bloodstream. (Morphine was the first intravenous drug.) Wood reasoned that if morphine were injected instead of ingested, people wouldn’t develop an “appetite” for the drug. He believed that he had found a way to separate morphine’s analgesic properties from its addictive properties. By 1880, almost every physician in the United States owned a hypodermic needle and began instructing patients on how to inject morphine on their own. Wood’s wife would later die from a morphine overdose—the first recorded patient to die from an injectable drug.

  With the invention of the hypodermic syringe, morphine became the addict’s drug of choice. By 1900, more than 300,000 people in the United States were addicted to morphine. When laws were passed to prohibit its sale, the demographics of addiction quickly shifted. No longer were addicts the frail, sympathetic, laudanum-drinking women of To Kill a Mockingbird; they were poor urban males like Frankie Machine, the hustling, pool-playing junkie in Nelson Algren’s best seller The Man with the Golden Arm. (Frank Sinatra played Machine in the 1955 movie.)

  It was back to the drawing board. Was it possible to invent a pain-relieving medicine that had the power of opium—and its principal component, morphine—without causing the addiction and dependence that invariably accompanied the drug? At this point, scientists had used only products found in nature. Surely, there must be a way to use modern chemistry to synthesize a nonaddictive painkiller. In the late-1800s, one scientist believed he had discovered it: the holy grail of pain relief.

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  IN 1874, A PHARMACIST in London named C. R. Alder Wright boiled morphine with the reactive form of acetic acid (vinegar) on a stove for several hours, producing diacetylmorphine. (This process is called acetylation.) Convinced that he had finally created a nonaddictive pain reliever, Wright fed the gray-white powder to his dog, who became frighteningly hyperactive, violently ill, and almost died. After throwing away the powder, he published his findings in the Journal of the Chemical Society in London. Although Wright would soon become a Fellow of the prestigious Royal Society, nobody paid attention to what he had written.

  Twenty-one years passed.

  In the late 1800s, Heinrich Dreser, a young chemistry professor working for a struggling pharmaceutical company in the Rhineland, discovered Alder Wright’s article. Like Wright, Dreser wanted to rid morphine of its addictive properties. He was impressed by Wright’s paper. Dreser knew that by acetylating morphine, the drug could enter the brain more quickly. Therefore, much less morphine would be required for pain relief. With so little drug required to induce a biological effect, Dreser reasoned that people would be much less likely to become addicted to the drug. At last, a safe, effective pain reliever.

  In 1895, Dreser instructed his assistant, Felix Hoffmann, a postdoctoral student, to acetylate morphine. This was nothing new to Hoffmann, who had recently acetylated another chemical, sodium salicylate, which had been used as an anti-inflammatory drug to treat rheumatism. The problem with sodium salicylate was that it damaged the lining of the stomach, causing gastritis, bleeding, and occasionally ulcers. Hoffmann found that by acetylating sodium salicylate, resulting in acetyl salicylic acid, the gastritis problem virtually disappeared. In 1899, Dreser and Hoffmann’s company—which was named for its founder, Friedrich Bayer—marketed its new drug, calling it Bayer Aspirin.

  Now, Dreser and Hoffmann were ready to see if their success with aspirin would carry over to morphine. So they fed diacetylmorphine to a few rats and rabbits that appeared to love it. Then they fed the gray powder to four workmen in the company who also loved it; indeed, the workers were anxious to repeat the experiment. Then they tried the drug on a few local patients.

  In September 1898, Heinrich Dreser presented his findings at the 70th Congress of German Naturalists and Physicians. Dreser claimed that diacetylmorphine could treat colds, sore throats, and headaches, as well as severe respiratory infections like pneumonia and tuberculosis—two leading causes of death. Further, diacetylmorphine was five times more potent than morphine and completely non–habit forming. (At this point, Dreser had tested the drug on only a handful of people for about four weeks.) Dreser believed that he had found the perfect drug to treat morphine addiction. Attendees at the conference gave him a standing ovation.

  Dreser didn’t have to work hard to convince Bayer executives to launch the new drug. But first they had to come up with a name. Some of the workers wanted to call it wunderlich, meaning miracle. But Dreser preferred the name heroisch, meaning heroic. In 1898, Bayer launched their new drug, calling it heroin. Aspirin, which physicians worried might cause gastritis, could be obtained by prescription only. Heroin, which was believed to be much safer, could be purchased over the counter.

  In 1900, Eli Lilly, working in collaboration with Bayer, began distributing heroin without prescription in the United States, promoting it side by side with aspirin as a treatment for colds and the flu. Lilly claimed that the drug could be given safely not only to children, but also to infants and pregnant women.

  Heroin sales took off. First, the military administered the drug intravenously to its soldiers in the field during World War I. Then, citizens bought heroin in the form of cough lozenges or as an elixir mixed in glycerin. Millions of doses were sold in England and the United States. In the early 1900s, the philanthropic Saint James Society launched a campaign to send free heroin to morphine addicts.

  Heroin became a standard of care. In 1906, the Journal of the American Medical Association stated that heroin was “recommended chiefly for the treatment of diseases of bronchitis,
pneumonia, consumption [tuberculosis], asthma, whooping cough, laryngitis, and certain forms of hay fever.”

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  IT DIDN’T TAKE LONG TO REALIZE that heroin wasn’t what it was claimed to be.

  By 1902, at least a dozen cases of addiction and some infant deaths had been reported. By 1905, the evidence was overwhelming. Because heroin crosses the placenta, infants born to heroin addicts suffered symptoms of severe withdrawal. Traces of heroin could also be found in breast milk. In 1906, the Council on Pharmacy and Chemistry stated, “The habit is readily formed and leads to the most deplorable results.” By 1910, doctors were fully aware of the dangers of heroin, and its use declined. Bayer, on the other hand, didn’t stop advertising the drug as safe until 1913. By 1918, more than 200,000 people living in New York City alone were addicted to heroin.

  In 1924, Congress passed the Heroin Act, making manufacture and sale of the drug illegal. As a consequence, heroin went underground. In the 1920s and early 1930s, heroin’s principal distributors were mobsters Meyer Lansky, Dutch Schultz, and Legs Diamond. (Because all three were Jewish, heroin was often called “smack,” from the Yiddish word schmecher, meaning “addict.”) In the mid-1930s the Italian Mafia took over, specifically, Charles “Lucky” Luciano, who established the “French connection.” Opium grown in French Indochina or Turkey was shipped to Lebanon where it was converted to morphine and then shipped to the French port city of Marseille where it was processed into high-quality heroin and smuggled into the United States.

  Initially, heroin abuse was confined to a poor, urban underclass. By the 1940s, however, heroin addiction had spread to the Harlem jazz scene, and by the 1950s—through the writings of Jack Kerouac and William Burroughs—to the beat generation. By the mid-1960s, more than 500,000 Americans were addicted to heroin. Virtually all major U.S. cities, as well as countries like Britain, France, and Germany, were caught in heroin’s snare.

  The U.S. government took action, pressuring Turkey to stop producing opium and eliminating importation of heroin from France. (This success was dramatized in the 1971 movie The French Connection, starring Gene Hackman and Roy Scheider.)

  By the 1970s, opium production had moved to an area in the highlands of Laos, Thailand, and Burma (now Myanmar), known as the Golden Triangle. No group suffered this switch in opium production more than American soldiers in Vietnam, about 15 percent of which became addicted to heroin.

  In the summer of 1971, President Nixon declared an “all-out war on drugs.” “America has the largest number of heroin addicts of any nation in the world,” he said. “If we cannot destroy the drug menace in America, then it will surely in time destroy us.” Nixon chose Elvis Presley to be the public face of his war on drugs. Ironic, given that at the time of Presley’s death in 1977, Valium, methaqualone, morphine, codeine, and barbiturates were found in his bloodstream. Presley wasn’t the only celebrity to die from a drug overdose: Janis Joplin died in 1970, John Belushi in 1982, Chris Farley in 1997, and Philip Seymour Hoffman in 2014, all from heroin overdoses.

  By the mid-1990s, heroin—which had become cheaper and purer—could be liquefied on tinfoil and its vapors inhaled (called “chasing the dragon”). Now more women started to use the drug. By 1995, more than 600,000 Americans were addicted to heroin. In addition to the Golden Triangle, the Medellin cartel in Colombia also produced large quantities of the drug. The Drug Enforcement Agency, which now had more than 75 offices in 50 countries, was spending more than $13 billion a year trying to keep heroin out of the country.

  By 2003, the number of Americans addicted to heroin had decreased from 600,000 to a little more than 100,000. This decrease wasn’t because Americans had lost interest in narcotics. It was because they had again replaced one addiction with another.

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  SCIENTISTS HAD HOPED that morphine could treat opium addiction. Then they had hoped that heroin could treat morphine addiction. It was time to try something else. Again, they would synthetically modify a drug to separate pain relief from addiction. And again, they would fail. This time, spectacularly.

  To find the next wonder drug, scientists turned to another component of opium: thebaine, named for Thebes, a town in ancient Egypt where the opium poppy was grown. The first synthetic version of thebaine was produced in 1916 by two German chemists working at the University of Frankfurt. They called it oxycodone.

  In the early 1950s, oxycodone made its American debut. Initial preparations were combined with a variety of other drugs. For example, there was Percodan, a combination of oxycodone and aspirin; Combunox, a combination of oxycodone and ibuprofen, a nonsteroidal anti-inflammatory; and Percocet, a combination of oxycodone and acetaminophen (Tylenol). But the single most powerful, and eventually most addictive and most abused preparation, was OxyContin, pure oxycodone uncut by other drugs. OxyContin’s manufacturer, Purdue Pharma, marketed the drug as a first-line agent for arthritis. In OxyContin, Purdue Pharma had struck gold—the drug would eventually account for more than 80 percent of its business.

  Later, Purdue combined OxyContin with an acrylic that allowed for a slower, timed release of the drug, eliminating its need to be taken several times a day. Addicts soon found that by chewing the tablet or crushing it, they could bypass the timed-release mechanism and enjoy the immediate rush of as much as 160 milligrams of oxycodone, logarithmically greater than any other product on the market. Now addicts had the capacity to ingest a potentially lethal dose of the drug. (On a weight-by-weight basis oxycodone is actually more powerful than morphine.)

  When OxyContin first came onto the market in 1996, the label read, “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of the drug.” Officials from the Food and Drug Administration (FDA) would soon regret this label. In the end, there was nothing controlled about the controlled-release form of OxyContin.

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  PHYSICIANS WERE INITIALLY wary of oxycodone. They had been burned by morphine in the 1800s, heroin in the 1900s, and opium since the beginning of recorded history. They didn’t want to be burned again. So they were slow to prescribe the next opium-derived miracle. By the mid-1980s, however, all of that would change.

  On April 20, 1948, Cicely Saunders, a nurse, joined St. Luke’s Hospital for the Dying in East London. Saunders believed that patients with terminal illness shouldn’t have to spend their last few weeks crying out in pain. Rather, they should die a dignified death—one as pain-free as possible. Saunders reasoned that it was better to prevent pain than to treat it. So, in 1967, she founded the hospice movement, providing dying patients with large quantities of addictive, pain-relieving medicines. Saunders’s movement crossed the ocean. In 1984, the United States Congress passed the Compassionate Pain Relief Act, making it legal to treat terminally ill patients with heroin. In 1986, Wisconsin launched the first state-based pain management program for cancer patients. Other states followed.

  For many patients suffering from terminal illnesses, vigorous pain management was a godsend. But a door had now been opened for doctors to prescribe long-term, high-dose narcotics. Initially, use was limited to patients with terminal cancer. Then a respected doctor from New York City took the liberal use of narcotics one ill-fated step farther.

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  IN 1986, RUSSELL PORTENOY, a 31-year-old New York City pain specialist, published a paper in the journal Pain. Portenoy believed it was time for American physicians to get over their fear of painkillers, what he called “opiophobia.” Portenoy reported the stories of 38 people who were on high-dose pain medicines (12 were on OxyContin). Only 2 of the 38 had become addicted to their drugs, and both had had a history of addiction. Portenoy argued that his findings weren’t unique; three previously published studies had also shown that less than one percent of patients on chronic painkillers had become addicted to them. Portenoy reasoned that, “opioid maintenance therapy can be a safe, salutary and more humane alternative [for] patients with intractable non-malignant pain and no history of drug ab
use.” Russell Portenoy believed that the compassion Cicely Saunders showed for patients with terminal cancer should be extended to all patients. Pain, argued Portenoy, should now be the fifth vital sign (in addition to temperature, blood pressure, heart rate, and respiratory rate). No one should be allowed to suffer. (One note on nomenclature: When Russell Portenoy used the term opioid, he was referring to synthetic forms of opium, like oxycodone. Morphine and codeine, which can be purified directly from opium without modification, are called opiates.)

  Charismatic, bright, and persuasive, Russell Portenoy became the media’s “go-to” guy for pain management, frequently appearing in newspapers and popular magazines. His academic success was also meteoric; Portenoy wrote or co-wrote more than 140 papers in medical and scientific journals and 15 book chapters. When Russell Portenoy talked, doctors listened. Portenoy had now given doctors permission to come back to opium derivatives. This time, he assured them, there would be little addiction and death. The days of opium, morphine, and heroin were behind them. Drugs like oxycodone had finally solved the problem of pain relief without addiction. Richard Nixon’s war on drugs had become Russell Portenoy’s war on the war on drugs.