Evidence found in a Sumerian
ideogram, depicting the opium poppy as "the plant of joy",
suggests that this flowering plant was domesticated for its pharmacologically
active milky white juice as long as 8,000 years ago. A papyrus dated 1552
B.C. advises Theban physicians on the use of opium in hundreds of potions
for myriad "medicinal" purposes. Arab, Greek, and Roman physicians
described opiate toxicity in the 2nd century B.C., and Nero, the Roman
emperor, took advantage of this quality of opium by intentionally overdosing
Brittanicus in A.D. 55, taking his throne. Egyptian documents describe
the use of opium for pain relief, as do the Romans, around this same epoch.
During ancient times, consumption of opiates (a term referring to the
alkaloid derivatives of opium) became routine, even commonplace, among
many seemingly upstanding citizens, and there is documentation that this
occurred without the pathognomonic dose escalation and dysfunction attributed
to addiction. Galen, for instance, reported that the political leaders
of the day could distinguish the quality of the ingredients of their opiate
concoctions, reducing consumption when necessary to execute their duties.
In the 16th century, both German and British physicians commonly prescribed
opium admixtures, under the rubric of laudanum, for a variety of ailments.
This soon became associated with quackery, since it was purported to be
a panacea for all ills at a time when at least some rigor in medicine
was being demanded. It was also around this time that there were observations
describing tolerance and physical dependence.
By the turn of the next century, two schools of medicine had diverged
in France. In the southern regions, physicians preferred "tonics,"
whereas northern practices influenced by Parisian schools of thought placed
great reliance on blood-letting and purging. The former approach was adopted
by the English physician, Thomas Sydenham. He, too, used the term laudanum
for his alcohol-opium tincture. He wrote, "So necessary an instrument
is opium in the hand of a skillful man, that medicine would be a cripple
During the 17th and 18th centuries, physicians and pharmacists throughout
England, France, and Germany experimented with a variety of formulations
and means of administration in both humans and animals. Physical dependence,
manifest by an acute abstinence syndrome, became well known, mostly in
those using opiates for what today we would probably classify as mood
disorders (anxiety and depressive illness). This era is marked by a substantial
increase in the use of psychoactive drugs in Europe for purely experiential
Concurrently, British commercial interests expanded the opium trade from
India to China. This trade became a major revenue generator and offset
the trade deficit from Chinese silk, spices, and other commodities. The
opium trade had a devastating effect on productivity of Chinese peasants,
and in 1799, the Emperor of China issued a proclamation that prohibited
importation of opium. This had limited effect, as the market (demand)
exceeded the capacity of imperial rule to stop the trade.
In 1805, Friederich Wilhelm Sertürner, an apothecary's assistant
in Hanover, Germany, isolated a white crystalline powder from opium that
he thought would explain the sleep-inducing quality of the parent compound.
He called this purified product morphium, after the Greek god of dreams
and sleep, Morpheus. Apparently, he was not a disciplined scientist, and
his eccentricities delayed appreciation of his discovery for more than
The Parisian pharmacist Pierre-Jean Robiquet perfected an extraction process
for morphine, and it was soon promoted as both an analgesic and a cure
for opium addiction. Commercial morphine appeared in London in 1821, and
wholesale production by the German pharmacist, Heinrich Emanuel Merck,
began a few years later.
With the development of the hypodermic syringe in the mid-19th century,
morphine could be injected directly into painful areas (called neuralgias),
with the thought that this would induce a localized anesthesia. In Victorian
times, neuralgias were attributed to both sexual repression and over-indulgence.
Ironically, the inventor of the hypodermic syringe, Dr. Alexander Wood,
an Edinburgh physician, was convinced that injection of morphine, in contrast
to oral ingestion, would obviate the growing problem of morphine addiction.
Diacetylmorphine was synthesized during the latter part of the 19th century
by the English chemist, C.R. Alder Wright, and it was soon found to be
effective for the relief of respiratory symptoms by Heinrich Dreser, chief
pharmacologist for the German pharmaceutical company, Bayer. Bayer marketed
this synthetic opioid (a term referring generically to alkaloids, their
synthetic derivatives, and physiological substances with similar effects)
as a cough suppressant under the trade name "Heroin."
It was introduced to British physicians in a Lancet report, which stated
that heroin is not habit forming. The assumption that heroin might be
useful to wean morphine "habitués", of course, proved
to be disastrous, and was compounded at the turn of the 20th century,
when legislation proscribing opium smoking led to an increase use of heroin
by intravenous injection.
Early in the 20th century, growing use and abuse of opioids and other
drugs in the United States led to increasing public concern, and reaction
by politicians. In 1906, the Pure Food and Drug Act was passed, which
gave the government the obligation of regulating drugs and establishing
their safety and efficacy before entry into the U.S. market. This was
followed in 1914 by the far-reaching Harrison Narcotics Act, which applied
controls to opioid drugs and, among other features, prohibited physicians
from prescribing opioid drugs to addicts. In 1919, the Supreme Court upheld
this law (Webb et al versus the United States) and stated that a physician
must not provide opioids for the purpose of maintaining an addict. Dispensing
centers for maintenance were closed, driving procurement underground.
Addicts who obtained drugs illegally became criminals, and drug use was
increasingly viewed as being under the purview of the criminal justice
system, rather than the health care system. In 1937, the Marijuana Tax
Act outlawed cannabis and heroin, adding further aspects of drug use to
the criminal code.
Throughout the 20th century, efforts to stem abuse and addiction through
law and regulation surged in the United States. In 1970, the Federal
Controlled Substances Act increased the monitoring of the manufacture,
prescribing and dispensing of opioids and other controlled drugs. It required
registration of all prescribers of controlled drugs, and categorized potentially
abusable drugs into five schedules, each with different regulatory mandates.
The law stipulated that drugs in Schedule II, such as morphine, could
not be prescribed by telelphone, nor could they be refilled without a
new written presciption. These federal efforts were mirrored at the state
level, where a complex array of laws and regulations created further requirements
for prescribers and patients, and an additional set of civil and criminal
penalties that could be applied to those prosecuted.
This societal decision to regulate medical practice and criminalize the administration of opioid drugs
in some contexts led to secondary phenomena, with effects of their own.
Prescribers became increasingly concerned about the potential for investigation
and sanction or prosecution. To some degree, this concern has contributed
to the underuse of opioid drugs. Equally important, the criminalization
of opioid addiction fostered an illicit drug trade that, in turn, brought
new problems, including the involvement of organized crime and violent
gangs in drug trafficking. Over time, all these problems--the undertreatment
of pain, the occurrence of opioid abuse and addiction, and the criminal
activities surrounding opioid trafficking--have increasingly undermined
the public health. Clearly, pursuant to pain management and opioid analgesia,
there is a pressing need for rational and consistant policies, initial
and continuing education of healthcare professionals, and application
of sound principles of assessment, prescribing, and management.
| Read more. Fine P, Portenoy
RK: Opioid analgesia. New York: McGraw Hill, 2004. Download
The intent of this book is to help clinicians make practical sense
of the varied and often conflicting issues (pharmacological, clinical,
and regulatory) surrounding opioid pharmacotherapy, in order to promote
the most healthful outcomes possible for patients in pain. The aim is
to improve knowledge and skills related to both the principles of prescribing
and the management of risk. In this way, healthcare professionals and
those they serve may benefit increasingly from the unique therapeutic
potential of this drug class, and fear less the undeniable, yet manageable,
potential for harm.