The History Of Drug Use

The usage of drugs and widely understood psychoactive substances have been known as long as humanity's recorded history lets us discover.

According to professor Elisa Guerra-Doce, people have tried to alter their consciousness ever since prehistoric times:

"(...) the evidence shows that people have been chewing the leaves of a plant called the betel since at least 2660 B.C (...) The plant contains chemicals that have stimulant- and euphoria-inducing properties, and these days is mostly consumed in Asia.

The earliest evidence of opium poppy use in Europe comes from the Neolithic site of La Marmotta in Italy, which dates back to the mid-sixth millennium B.C., according to the study. The domestication of the plant in Europe likely began around that time, in the western Mediterranean, and then spread  to northwestern Europe by the end of that millennium." (Guerra-Doce, 2015)

In the cited fragment, the author mentions two plants – the betel, and the opium poppy – both of which might be familiar to the reader (however, as also stated in text, the western readers might be more acquainted with the latter), since their usage is still prevalent today. It is important to note that, nevertheless, there was no sudden revival of the usage of certain substances, but they were the subject of a custom thorough the time leading to the present day. The author of the official website of The International Network of People who Use Drugs presents the timeline of drug usage – including mainly opium, as well as various stimulants, but also mentioning widely consumed and , in most cases, legal products, that contain an addictive component, like coffee, tea, and alcohol  – starting from the habits of the ancient Sumerians, up to the year 2014.

The report asserts that the beginning of opium usage outside of Europe ought to be placed in the year 5000 B.C., since the presence of a certain ideogram in the Sumerian writing system. However, there seems to be no trace recorded of any other drug thorough the next 1500 years – both in Europe and other parts of the world – when the first known use of alcohol is acknowledged in Egypt, and when the practice of drinking tea starts in China (which is also characteristic for the region even today). Aside from what can be learnt from Guerra-Doce, opium is tracked in the Old Continent yet again in present-day Switzerland, where it appeared in the form of edible seeds.

Interestingly (especially for the further part of the chapter), alongside with the description of drug use, the author also mentions the first ever attempt at substance prohibition. The Endeavour took the form of a religious teaching, which was conducted by an Egyptian priest, who forbade his listeners from visiting taverns, explaining that drinking alcohol would make them behave “degraded like beasts”.

The article then temporarily abandons strictly historical records, and, instead, focuses on the mentions of addictive substances in the Bible (which, obviously, influenced the behavior and attitude of its readers); the cited part (Proverbs, 31:6-7) encourages those who witness someone suffering to offer them alcohol, which will supposedly help the offered forget their hardships.The reference to Christianity also introduces the part of the report that concentrates on the A.D., with the words of the Bishop of Constantinople, St. John Chrysostom: “I hear man cry, ‘Would there be no wine! O folly! O madness!’”After that we learn about the start of the use of yet another popular substance, tobacco, in Europe – the drug was imported to his homeland in 1493 by Christopher Columbus, who encountered its usage during one of his voyages.

What is common for all the aforementioned records is that the use of the substances was purely recreational (with the possible exception of alcohol being the cure for misery – still, it cannot be considered an appropriate medical remedy). Outlining the beginning of the 16th century, however, the author brings up the Swiss alchemist, Paracelsus, who was the first to propose opium as a means that can be used in medicine (which, on the other hand, is essential for latter chapters); yet, the acclaimed researcher specified neither the particular branch of medicine papaversomniferum (the scientific name of poppy plant) could be applicable for, nor the particular issue opium could be a cure for. It is possible that in the light of seemingly positive effects it had on the users' mental state (albeit only temporarily), Paracelsus suspected the properties of opium could be somehow introduced into the methods of an actual therapy.

After describing several other attempts at prohibition (namely by czar Michael Fedorovich and Sultan Murad IV; focusing mainly on tobacco, both the user and the supplier were to be tortured or executed), the above-mentioned ambiguity is cleared by pointing out the statement of the English physician, Thomas Sydenham, who attributes unprecedented and exceptional painkilling properties to opium: “Among the remedies which it has pleased the Almighty God to give to man to relieve his sufferings, none is so universal and efficacious as opium.”

En passant, a worth mentioning and thought-provoking employment of consciousness-altering substances can be found in the 18th century England: only those who “would take oaths of allegiance and of belief in the King’s supremacy over the Church” could be allowed to consume alcohol legally. This exception from prohibition is a clear example of a benefit offered in exchange for political gain.

With the passage of time, however, the attitude towards certain addictives began to change, according to the author. Shortly after the first known inclusion of drugs in politics, at the other side of the Atlantic Ocean, in Connecticut, the first temperance group started, focusing principally on alcohol addiction and abuse.

Accordingly, in their book Drugs in American Society: An Encyclopedia of History, Politics, Culture, Nancy E. Marion and Willard M. Oliver (2014) described alcohol usage as:

"(…) a disease, produced by a remote cause, and giving birth to actions and movements in the living body that disorder the functions of health. The habit of drunkenness is a disease of the mind." (p. 54)

Likewise, looking to the East, in 1792 Chinese rulers passed the law that prohibited the usage of opium, under threat of capital punishment.

Nevertheless, the growing animosity towards drugs (at the time mainly alcohol and opium) did not prevent the emergence of different substances. Near the end of the 18th century, cannabis – another well-known (as well as controversial, due to varying restrictions around the world) modern drug – arrived to France as a consequence of Napoleon Bonaparte's return from Egypt, where it had already been in use.

Few years later, at the beginning of the 19th century, opium became the center of attention in the world of medicine yet again, as a derivative of the drug, morphine was isolated in Germany. FriederichSerturner, who conducted the procedure, first tested the effects of morphine on dogs, describing it as a “sleep-inducing molecule” (which came to him as no surprise, since the sedative impact of opium on the organism). Later, after risking self-medication with his discovery that, ultimately, brought him relief and left no negative side effects, he began to test continuously morphine on volunteers, including himself. Finally, he was able to determine an efficient, yet safe oral dose (as medical syringes had yet to be devised by the time of Serturner's discovery), and, in the same decade, he opened a pharmacy in northwestern Germany.

Despite earlier claims and research on the painkilling effects of poppy plant, FriederichSerturner's work marks the official introduction of an opium-related medication to the market. Interestingly, morphine was advertised not only as a pain reliever, but as a medicine with various other qualities (some of the qualifying as meeting the criteria of recreational use), such as documented by Chandrasekhar Krishnamurti and Chakra Rao (2016):

"(...) anxiolysis, euphoria and feelings of relaxation. (...) The drug is also dramatically effective in cardiogenic pulmonary oedema as it calms the patient and reduces dyspnoea and myocardial oxygen demand."

At that time, addictive purposes of opium were not widely discussed, or even known. In 1822, Thomas De Quincey, whose signature work, Confessions of an English Opium Eater, is believed to have introduced the topic of drug dependency into popular literature, wrote:

"Making allowance for constitutional differences, I should say that *in less that 120 days* no habit of opium-eating could be formed strong enough to call for any extraordinary self-conquest in renouncing it, even suddenly renouncing it. On Saturday you are an opium eater, on Sunday no longer such." (p. 34)

Taking the drug's apparent non-addictiveness and medical versality, the demand for papaversomniferum, had siginifically increased since the discovery of morphine. In 1839 however, the export of opium from China (the main supplier) to Europe through British East Indian Company, was at the risk of being halted entirely, as the Daoguang Emperor, concerned about the rising number of opium-related problems (mainly the issue of addiction that increased after the EIC started to illegally grow the plant in India – in contrast to Western societies and governments, Chinese rulers had not only been interested in the positive properties of the drug, but also were not oblivious to its disadvantages and tried to warm the citizens about them), did not agree to legalize the culture of the plant, and tried to stop the trade.

When the Emperor's diplomatic attempts at abolishing the sale failed, the General Governor of Hubei and Hunan provinces ordered to forcefully impound all opium from the western sellers' shops, and ordered the incoming ships to give up their cargo.

This measure resulted in the British deploying their military to China (thus starting the war), and ultimately, defeating the much more numerous Chinese forces. The First Opium War resulted in the Treaty of Nanking being signed; the document allowed free trade with Western merchants, as well as ordained the opening of five new ports.

The unrest related to opium did not decrease the interest in the manufacturing and distribution of other substances in the West, mainly thanks to the popular figures involved in the process. Abraham Lincoln mentions his doubts related to the temperance movement in his Temperance Address from 1842:

“In my judgment, such of us as have never fallen victims, have been spared more from the absence of appetite, than from any mental or moral superiority over those who have. Indeed, I believe, if we take habitual drunkards as a class, their heads and their hearts will bear an advantageous comparison with those of any other class. The demon of intemperance ever seems to have delighted in sucking the blood of genius and of generosity. What one of us but can call to mind some dear relative, more promising in youth than all his fellows, who has fallen a sacrifice to his rapacity?” (p. 272)

Nevertheless, despite such assessment from the president, the Temperance movement was still active. Three years later after Lincoln's speech, the State of New York delegalised public sale of liquor. The ban, nonetheless, lasted only two years before being overturned in 1847.

The attempts at restricting the sale and consumption of alcohol might have been unsuccessful at the time, but the foundation of The American Pharmaceutical Association at the beginning of the new decade seemed to have established – albeit not as strict – but a similar goal in association with pharmaceuticals (1958):

“(...) to aid in the detection of prevention of adulteration and misbranding or drugs and medicines (…) To support a system of of licensure and registration of pharmacists which will assure to the public the the availability of competent personnel to discharge the accepted functions of the practice of pharmacy and assure the availability of pharmacists and pharmaceutical service which will provide at all times for the distribution of drugs and medicines under the supervision of qualified pharmacists.” (p. 4)

Similarly, education and supervision became the main purpose of action of the Temperance movement, as well as other parties concerned with the problem of substance dependence (in the wake of such shift in the methods of preventing addictions, The Personal Liberty League of the United States was created). By the year 1900, all states have been subjected to laws introducing “temperance education” as a part of school curriculum.

It is worth noticing that the establishment of  The Personal Liberty League of the United States did not prevent the exclusion of certain people from being subjected to forceful abolition. Henry Cabot Lodge, a senator from Massachusetts, proposed a bill that did not allow the sale of liquor and opium to “aboriginal tribes and uncivilized races (…) uncivilized elements in America itself and in its territories, such as Indians, Alaskans, the inhabitants of Hawaii, railroad workers, and immigrants at ports of entry”.  

The beginning of the new century was marked by the growing suspicion of opium and its derivates (but also a fairly new invention and a stimulant, cocaine) for not being only a miraculous cure for pain. In 1905, Senator Henry W. Blair concluded:

“The temperance movement must include all poisonous substances which create unnatural appetite, and international prohibition is the goal.”

The skepticism resulted in the establishing of Pure Food and Drug Act – the sale of any derivative of opium was banned until the product was labeled as containing such substances. (Around the same time, Coca-Cola removed cocaine as one of the ingredients, and replaced it with caffeine).

Soon, the concern was not only limited to politicians, but also spreaded among general population. Dr. Charles B. Towns (1914) wrote in his article in the Century Magazine, pointing at analogous properties of tobacco, alcohol, and opium:

“A boy always starts smoking before he starts drinking. If he is disposed to drink, that disposition will be increased by smoking, because the action of tobacco makes it normal for him to feel the need of stimulation. He is likely to go to alcohol to soothe the muscular unrest, to blunt the irritation he has received from tobacco. From alcohol he goes to morphine for the same reason. The nervous condition due to excessive drinking is allayed by morphine, just as the nervous condition due to excessive smoking is allayed by alcohol(...) Morphine is the legitimate consequence of alcohol, and alcohol is the legitimate consequence of tobacco. Cigarettes, drink, opium, is the logical and regular series.”

Finally, in 1914, with the introduction of The Harrison Narcotics Tax Act, the sale of opiates and products containing cocaine was strictly regulated (although, the latter could still be distributed under certain conditions). The Act omitted marijuana, a substance that grew in popularity, mainly due to this sole reason.

This changed in 1937 with the enacting of The Marijuana Tax Act. Commissioner Harry J. Anslinger noticed:

“How many murders, suicides, robberies, criminal assaults, hold-ups, burglaries, and deeds of maniacal insanity it [marijuana] causes each year, especially among the young, can only be conjectured.”

As with any of the aforementioned cases of banning or restricting the use of addictive substances, the 1937 act received  vocal criticism. In The Marijuana Bugaboo, colonel J.M. Phalen asserted that the effects of the usage of cannabis are no more harmful than the effects of smoking cigarettes. He also maintained that there would not be any persecution of soldiers (the article was published in 1943) using the drug as he did not consider it a problem of any kind.

The negative effects of widely known addictives – especially alcohol – began to be recognised more often, and became more available to the population, mainly thanks to the popular figures involved in the process.

However, when it comes to mainstream consciousness, drugs became popularised in the 1960s, as their usage, together with colorful clothes, flower-painted vans, and music festivals was one of the characteristics of the “age of love”, the peak popularity of hippy subculture. As stated in Drug Enforcement Administration, A Tradition of Excellence (2009):

“In 1973, President Richard Nixon declared “an all-out global war on the drug menace” and sent Reorganization Plan No. 2 to Congress. “Right now,” he pointed out, “the federal government  is fighting the war on drug abuse under a distinct handicap, for its efforts are those of a loosely confederated alliance facing a resourceful, elusive, worldwide enemy. Certainly, the cold-blooded underworld networks that funnel narcotics from suppliers all over the world are no respecters of the bureaucratic dividing lines that now complicate our anti-drug efforts.” (p. 13)

Richard Nixon also requested establishing a federal agency that would integrate the government’s politics concerning prevention of drug abuse and trafficking; the proposal provided the basis for the creation of DEA (United States Drug Enforcement Administration). DEA would take over the drug enforcement operations of the consequently destabilished Bureau of Narcotics and Dangerous Drugs.

The Senate referred to the Federal Bureau of Investigation's broadened role in the field (DEA would be permitted to use the data FBI has obtained on drug-related crimes), coordinating the extortions of various local and foreign organs specialising in working against narcotic (as well as citing the assets of general administration, inter alia, diminished susceptibility for corruption and abuse of power), and determining the creation of the DEA as the catalyst for the mutual efforts of all other forces to be condensed together in order for the to result in a more successful outcome as the main benefits of the creation of the new agency.

One of the crucial factors in carrying out fruitful operations was efficient and trusted intelligence. The author describes the need:

"Accurate and up-to-date information was required to assess the operations and vulnerabilities of criminal networks, to interdict drugs in a systematic way, to forecast new methods of trafficking, to evaluate the impact of previous activities, and to establish long-range drug strategies and policies. Included in the DEA mission was a mandate for drug intelligence."

The mandate was passed and at the beginning of July 1973 the DEA established its own Office of Intelligence. Similarly to the base for creating the entity itself, the benefits of the coordinated efforts of non-federal agencies was quoted as one of the biggest advantages of the the newly-established office, together with identifying the past mistakes and insufficiencies in drug enforcement.

The office comprised of three main branches of interest: operational (analysis of the obtained data), tactical (finding and identifying drug traffickers), and strategic (recognising a general pattern according to which traffickers and producers operate).

Interestingly, shortly after the creation of the Office, the majority of those in charge of its operations did not have any experience in working in such field. According to the author, less than fifteen officials had worked as intelligence agents before. Such situation, however, did not prevent the DEA from creating its first task force - still in 1973. The UID (Unified Intelligence Division) and its achievements have been characterised by the author as:

"This pioneering role expanded the horizons of drug law enforcement field intelligence units, which, at the time, were often limited to collecting information, maintaining dossiers, and providing limited case support. This proactive stance was immediately successful as UID was able to develop and disseminate extensive intelligence on traditional organized crime-related drug traffickers and identify not only the leaders, but also those who were likely to become leaders."

The compelling activities of the division carried out through the next decade; the operations of the UID were the main factor in the decrease of cocaine abuse on the East Coast.

Despite the success of the UID, the DEA had to also focus on other factors that would provide a fruitful fight against drugs - one of them being proper organization of the tasks and procedures. The role was appointed to the DECS (The Drug Enforcement Coordinating System). The system monitored all the activities and cases the DEA was currently working on - a measure that prevented different agencies from unnecessarily repeating their efforts, but, most importantly, the DECS ensured the safety of the agents and various other officials, who thus could be informed of the difficulty level of a certain case and, subsequently, of any jeopardy connected to it.

An office similar to DECS, NADDIS (National Narcotics Intelligence System) was also developed the year the DEA started; it was of great importance and interest, however, as it was the first index of the operations that involved minimum of manual effort, being highly computerised instead. The author concludes its formation as:

"(...) possible because the DEA was the first law enforcement agency in the

nation to adopt an all-electronic, centralized, computer database for its records. NADDIS, composed of data from DEA investigative reports and teletypes, provided agents in all DEA domestic offices with electronic access to investigative file data."

"Investigative data" referred not only to illegal manufacturers and traffickers, but also to the victims of drugs abuse. The aim of DAWN (Drug Abuse Warning Network) was to monitor the scale of the consumption of illegal substances in the United States. DAWN, nevertheless, did not rely only on sources connected to the DEA; the Network joined efforts with hospitals, tracking the admissions of the patients that suffered with the use of illegal drugs or used legal substances recreationally. The author provides a descriptions of the clinics involved in operations conducted by DAWN:

"Non-federal, short-stay general hospitals that feature a 24-hour emergency department (...) The data from this sample were used to generate estimates of the total number of emergency department drug episodes and drug mentions in all such hospitals."

The focus on short-stay hospitals appears to be important, as drug-related cases generally require immediate intervention, but a long-term stay after the treatment is, in most cases, needed.

The investigation of hospitals was supposedly linked to passing Narcotic Addict Treatment Act. The aim of the act was to identify and list the doctors (but also nurses) who admitted narcotics to their patients suffering with drug addiction as a treatment. As stated by the author, the act "eliminated the indiscriminate prescription

of narcotics to addicts and reduced the diversion of pharmaceutical narcotics."

When describing the versality of the DEA, it is important to yet again acknowledge one of the core reasons for its development - the diversity of resources, which, as a consequence, leads to the Department's functionality and high adaptability to disparate environments.

A year before President Nixon's declaration, the amount of heroin illegally trafficked from Mexico reached a record number (it surpassed the amount of the drug coming from Europe by forty percent). As the control of the trafficking was no longer manageable by the forces that usually operated at the southern border, the Mexican government asked The United States for cooperation. The request resulted in three separate applications of drug enforcement - Operation Special Enforcement Activity in Mexico, concentrated in Sinaloa and focusing on heroin and opium, Operation Endrun - in Guerrero, targeting marijuana trafficking, and Operation Trident (suspending the movement of other illicit substances).

The fight against drugs, however, was not limited to more “casual” forms of actions, like the aforementioned intelligence or dealing with border traffickers. The DEA yet again took advantage of the still fairly new tools that, thanks to their computerisation, proved to be very useful to their mission.

Due to the fact that video cameras in the seventies were much bigger and heavier than their today's equivalents, the agents used mainly sound recorders. The equipment, however still heavy and relying on batteries that often turned out to be of short durability, was concealed as a belt worn by the person underneath their clothes; still, this method could only be used it the member of the DEA was able to be physically present at the scene. If the situation required higher level of concealiblity, the so called “pen registers” were relied on. The author describes such interesting in a greater detail:

“Pen registers, or dialed number recorders, were more advanced than the older versions, which actually punched holes in a tape, similar to an old ticker tape, in response to the pulses from a rotary dialed phone.“

The then-available technology did not only help in obtaining evidence, but also made the communication between the staff (and, obviously, between the agents assigned to a certain mission) easier. No mobile phones were used at the time being (with an exception of a specific type of such device, yet it was used only by the DEA administration), but a radio system was soon established. The data sharing was far from ideal, especially due to the tardiness of the transmitters, yet its usage was beneficial for both the DEA and the BNDD.

A different, more scientific approach to technology was managed in a form of the examination of the captured substances in the chemical laboratories. At the beginning, the Administration was not in charge of their own exclusive laboratories, but rather was supported by various government offices concerned with chemical composition of drugs; they would later be conjoined into one system, under the supervision of the DEA, and characterised by the author as:

“(...) primarily responsible for performing the ballistics analyses of tablets and capsules, identifying newly-encountered compounds found in drug traffic, and conducting methods development. (...) The original chemist work force for these laboratories came from several field laboratories run by government agencies. The professional staffing of the six laboratories consisted of 36 “bench” chemists doing physical lab research, supplemented by five supervisory chemists.”

Finally, the technology that came into use was also present in forms fairly different from recording devices and laboratory glass.

With the expansion of drug trafficking, it soon became clear that the issue could no longer be monitored only by ground patrols; yet, when the idea of using aircraft in order to track the traffickers was first conceived, the DEA did not have resourses sufficient to acquire a plane. Nonetheless, the concept ended up being put into execution, mainly thanks to the retired air force pilot, simply known as “Joseph” - the Administration was granted a military assistance (an operation possible in cases of organs of the government) in a form of a plane.

The idea produced a very successful, desired outcome and, still in 1973, the DEA (or, more specifically, its Air Wing) was in possession of over twenty single-engine planes.

The beginning of the 1970s marks the start of the organised policy concerning the prevention of drug trafficking and substance abuse, as well as the elimination of already existing issues, hence the time period was discussed and focused on the most above. The description of the methods used by the assigned forces, as well as the recounting of the introduction of various substances into the human society at various stages of its development, were also conductive to understanding the mechanics of physical and mental addiction.

What is more, the depiction of both the fight against drugs and their continuous presence in the life of a man, illustrates yet another matter – the continuity of the said process. The War on Drugs is but the most popularised of its stages; as mentioned in the earlier parts of the chapter, the first ever (recorded) attempt at prohibition took place in the ancient Egypt, followed by numerous later attempts, but so did the usage of drugs, alongside with the efforts to diminish the notion of their negative effects on health in the people's consciousness (e.g. the comparison of cannabis to tobacco).

Conclusively, the mechanism is still present nowadays.

The indication for the process reoccurring in the last decades became most noticeable at the end of the twentieth century. The diagram presented below illustrates the number of deaths related to abuse of prescription opioids, as compared to heroin (diacetylmorphine) and other drugs of the same type (according to CDC Wonder):

 

The issue of the growing number of prescription opioids overdoses spiked rapidly at the end of the 1990s, together with the general number of deaths caused by related substances. Interestingly, the level of heroin usage did not increase up until over a decade later, where a slight decrease in the overdoses on the legally distributed substances can be spotted. Such interchangeability suggests a correlation between both types of opioids, the possibility of one being successfully replaced with the other as the subject of addiction.

When presented with the theory, one might argue that even though the drugs prescribed medications come from the same drug class as the illegal items, the former must have specific indications of being non-addictive, or at least less harmful than the latter, since it is sold in accordance with the law. Whereas such logic appears to be reasonable, the rationale for the pharmaceuticals as the “safe version” of opioids can be demystified by comparing the properties of both.

(The medicament used for comparison in the drug OxyContin, as the agent quoted above describes it as the most abused prescription drug in the US.)

According to the Californian drug recovery facility, New Life House:

"users seek the euphoric, pain relieving and sedative effects (...) Some possible signs of Oxycontin abuse are lethargy, stoned appearance, pinpoint pupils, constipation, loss of appetite, and lack of interest in recreational activities".   

In his book Dope Double Agent: The Naked Emperor on Drugs, author Michael Agar (2006) describes his own experience with opioids, albeit the outlawed ones. The summary of his involvement with heroin can further serve as a matter of the aforementioned comparison:

“Patrons sat along the bar like birds on a wire. I nodded at a couple I knew by sight. (...) I looked around at the empty bar stools, trying to decide where I’d sit. Then it hit me – I didn’t give a shit. In fact, I didn’t give a shit the rest of the evening – it didn’t matter what anyone said or did. It didn’t matter if I spilled my drink or not. It just didn’t matter. I was always pretty relaxed in Stryker’s, but I was even more relaxed than usual. I just didn’t have a care in the world.” (p. 173)

The focus on the sedative and calming properties of both substances reads as the most distinguishable. This comes as no surprise, since opioids are well-known for such inducing such effects, which has also been mentioned earlier in the description of FriederichSerturner's work on poppy plant.  

As the data and testimonies provided above helped establish that legally sold opioids (OxyContin) possess the same or very similar qualities as heroin (diacetylmorphine) it is important to focus on the issue of safety yet again. How is that possible that despite almost twenty thousand deaths in 2014 caused by pharmaceutical painkillers, they are still being marketed? Why is their striking similarity to delegalised substances not an indicator of them also becoming outlawed?

First and foremost, it is only logical that no substance would be marketed as a painkiller if it did not provide painkilling attributes. In this case, the medicines work by stopping certain neurotransmitters from receiving signals responsible for provoking pain-inducing reactions. Such process proves to be effective as, according to the 2014 report by Medical Magazine, all ten most popular painkillers in the USA are opioids (four of them being based on oxycodone, the substance sold primarily under the name OxyContin).

RxList, in their section dedicated to pain management, provides the explanation for such phenomenon and proof of the effectivity of opioids:

“Opioid analgesics, in general, are the strongest pain-relieving medications. The benchmark drug in this class is morphine (...) Opioids more powerful than morphine include hydromorphone (Dilaudid) and oxymorphone (Opana) [Opana has already been removed from the marked due to large scale of abuse]. But the strongest opioid in community use is fentanyl which, in its intravenous form, is 70 to 100 times more potent than morphine. Fentanyl is also available as a long-release patch (Duragesic) and as a lozenge that dissolves in the mouth (Actiq). Sufentanil is even more powerful than fentanyl, but its use, at present is restricted to the intravenous route.”

That is, obviously, not to say that the noticeable benefits patients receive from opioid-based treatment diminish the data collected on lethal overdoses or prevent attempts to restrict or control the sale.

One of such pursuits gained considerable media attention in 2019, as CDC (The US Centers for Disease Control and Prevention) presented new guidelines for the sale and indications for prescribing opioid-based medicines. As summarised by the article published on the official website for American Physical Therapy Association, the content of the guideline raised concerns among patients suffering from chronic pain, as they feared they would no longer be allowed to obtain the medication that helped them alleviate their symptoms; what is more, numerous organisations concerned with oncology (opioids are also widely used in treating pain in patients with cancer) and hematology accused the CDC of helping create circumstances in which patients would consider bribing the doctor in order to be able to acquire the drug essential in their long-term treatment. The CDC responded to the complaints by stating:

“The Guideline was developed to provide recommendations for primary care physicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care (...) The Guideline is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management (...) the Guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options.”

According to the article, the mention of “all safe and effective treatment options” refers to non-opiod painkillers; such solution would prove to be beneficial, provided the use of the substitute substances possessed less or no risk of addiction and abuse. However, the report by Medical Magazine, as well as the data provided by RxList, remind one that the painkilling qualities of opioids are still considered the most effective. A long-time user of a certain pharmaceutical that provided them with successful pain management would also feel hesitant to trying a new, less known solution.

Likewise, one of the comments referring the article on the actions taken by the CDS helps better illustrate the issue from the perspective of the person directly concerned with it:

“I too live in severe chronic pain and have been reduced to a point that I don't sleep or want to eat so my weight has dropped to less than 100 pounds. I followed the instructions on my bottle religiously because I needed them to live a somewhat normal life. It is sad some choose to abuse but why are we punished for it. (...) The numbers are skewed and docs know who does and doesn't abuse we are monitored like children. WE ARE JUST AS IMPORTANT as those who choose to abuse or abuse street drugs...where is the compassion for us..the ones who can't be "fixed"?”

All the factors detailed above seem to have created a paradox that bars both parties – those that developed drug dependence because of improper usage and those that need certain medicines for legitimate causes – from receiving a helpful, safe solution to their dilemma. While opioids constitute a huge percentage of prescription misuse, and overdoses, no resolution has yet been provided that would arrest or at least reduce the issue without doing disservice to patients with chronic pain.

The purpose of the chapter was to not only familiarise one with the history of substance abuse, its characteristics in reference to specific drugs, but also to introduce the concept of prescription abuse and the concern of the shared origins of specific pharmaceuticals and illegal substances. Therefore, because of its purpose, the chapter does not detail specific cases, but simply helps illustrate the general issue.