The “Right” and “Wrong” Kind of Addict: Iatrogenic Opioid Addiction in Historical Context Jonathan Jones Science & Medicine Last year, Kelly McEvers of NPR’s Embedded podcast introduced us to Joy. Something about Joy seems so ordinary, even familiar. She’s a certified hospital nurse, a mother of three kids, and a former Girl Scouts leader. She’s from Indiana, America’s heartland. She’s even close with her parents. And like many of us, she suffers from chronic back pain. That’s where it all began for her. Joy’s story shocks the listener because it contradicts so many stereotypes about drug addiction. She isn’t the sort of character who typically comes to mind when we think of opioid addiction — but she does suffer from addiction to opioids. Badly hurt on the job one day after picking up a fallen elderly patient, Joy became addicted to the powerful opioid Opana to manage her pain. Opana is notorious for its extraordinary addictiveness — even compared to other synthetic opioids. The drug is so addictive that according to the FDA, its risks outweigh its benefits because it too often leads to iatrogenic opioid addiction, or addiction by way of medical care.1 Rather than through so-called “gateway drugs” or thrill-seeking behavior, Joy became addicted to Opana when a doctor prescribed the drug to treat her back pain after her workplace injury. She is one of the many people who become addicted to opioids iatrogenically, through treatment by doctors. Despite CDC guidelines recommending physicians avoid prescribing narcotics for lower back pain so as to prevent iatrogenic addiction, some forty percent of doctors still prescribe painkillers, including opioids, as first remedies for patients’ back pain. Opioid analgesics are currently the most commonly prescribed class of medications in the United States, leading to an iatrogenic addiction rate that may be as high as twenty-six percent of opioid addicts.2 This is exactly what happened to Joy. By the time her prescription ran out, she had become addicted to the opioids prescribed by her doctor. So she started buying Opana on the street. Joy certainly isn’t a unique case. Many people become addicted to opioids prescribed by their doctors, and are often forced to turn to illegal sources to prevent intensely painful and dangerous withdrawal symptoms after their prescriptions are cut off. When their stories become public, all too often we are shocked by the circumstances that lead such “ordinary” people to become addicted to opioids, the abuse of which entails tremendous social stigma. Opana analgesic tablets. (Tom Walker/Flickr | CC BY-NC) In the midst of an opioid epidemic that is spiraling out of control, cases of iatrogenic addiction among otherwise-ordinary Americans like Joy are increasingly visible reminders that there are many “kinds” of people who suffer from addiction. For example, iatrogenic addiction cases are often set in juxtaposition to those of individuals who become addicted to drugs through thrill-seeking or other risky behaviors. According to deeply-rooted cultural tropes, iatrogenic addiction is usually perceived to be a legitimate way become a drug addict, the “right” or justifiable path to addiction, while other routes to addiction create the “wrong” kind of addict. The right kind of addict deserves sympathy and medical help, while the wrong kind of addict should be left to face the consequences of their own choices, according to common sentiment.3 Traditionally, historians have believed that this delineation of routes to addiction into legitimate and illegitimate categories is a consequence of the Progressive Era-criminalization of narcotic addiction. According to this narrative, the stigmatization of non-iatrogenic addiction has its origins in social policing efforts like the Harrison Narcotic Act of 1914 and the concurrent professionalization attempts by groups like the American Medical Association.4 “The outfit of the opium smoker,” a photo of opium smoking paraphernalia. (World Health Organization/US National Library of Medicine) This argument unintentionally implies that the time before the early twentieth-century criminalization was a kind of “golden age,” when narcotics addicts were not implicitly segregated into classes of legitimacy based on their route to addiction. During this golden age, it follows, most physicians seem to have treated all addicts alike with common compassion through public health measures like addiction maintenance programs, akin to today’s methadone clinics.5 This precludes cases like that of Joy, who seem ordinary save for their “legitimate” addiction, because all kinds of addicts would have been treated with egalitarian compassion and medical attention. Sadly, this past is simply a pleasant fiction. Really, the segregation between the “right” and the “wrong” kinds of addicts is not a modern innovation at all. In fact, it has been a central characteristic in the American conception of drug addiction in the United States since the earliest recorded opiate addiction crisis, which emerged in the American medical consciousness during the 1830s. In 1833, the editor of the Boston Medical and Surgical Journal published an impassioned circular at the behest of a patient, a woman whose case was “of the most touching character.” He described with great empathy his efforts to cure the woman of her addiction to opium, which was iatrogenic in nature. The editor took pains to make sure his readers understand that the “lady” became addicted in the course of a doctor’s treatment for “nervous irritation,” a diagnosis that could not sully her character because physicians would have considered it appropriate for a woman.6 This legitimate route to addiction was what prompted the editor to pen this extraordinary article, which he opened by imploring his colleagues: “Is there any sure and safe method of curing a person of the habit of opium eating?”7 Tucked away in this relatively long editorial, in which the author expends about half of his words painstakingly validating the character of the patient on whose behalf he writes, is perhaps the earliest account in the historical record of the “wrong” kind of patient. The editor explains: When we allude to opium eaters, we mean those only who took it originally as a medicine for some nervous affection, and continue it from necessity, rather than from choice; — who take it, not to intoxicate, but to strengthen and balance the nervous system and enable them to attend to business, and to appear like other people. Of those who take opium for purposes of unnatural excitement and inebriation, we have no knowledge. They need less of our sympathy, and would excite us less to exertions in their behalf.”8 If one reads on, subtle, implicit gender and racial biases that inform the above statement become explicit. The woman in question, the legitimate “opium eater,” was the archetype of antebellum domesticity. She was a young “wife and mother, a neighbor and friend,” whom opium had made its “slave.” Because she otherwise fulfilled contemporary gender conventions dictating what middle-class white women should ideally be, the woman’s case called out “most loudly for the sympathy and aid of the humane physician.” By using language like “slave,” which readers likely would have taken as the author equating opium eating with racial slavery, the author also implies that legitimate opiate addicts must be white. Readers would have felt revulsion at this woman’s case, because through no fault of her own, opiate addiction had stripped her of an elevated status as a middle-class white woman and reduced her to a position of degradation, according to antebellum gender and racial constructs.9 Engraving depicting a San Francisco opium smoking “ranche” in 1900. (Time Life Pictures/Mansell/The LIFE Picture Collection/Getty Images) But what about the others, the illegitimate abusers of opium? They were not worthy of the physician’s empathy or help, both because of how they came to be addicted, and because they did not meet the expectations of antebellum gender and racial conventions of domesticity. This 1833 editorial suggests that from the earliest moments in the saga of opioid addiction in America, a central characteristic of the conception of addiction has been the delineation of legitimate and illegitimate pathways to addiction. Iatrogenic addiction has always been the “right” way to become addicted, rendering patients like the woman in this editorial worthy of empathy and medical assistance. And non-medical routes to addiction have always been the “wrong” way, making “drug addicts,” as these sufferers are often described, unworthy of assistance. Fast-forward to today, and Joy, the woman profiled in Embedded, has become the modern “legitimate” addict. Like the woman in the 1833 editorial, Joy seems to reach all the markers of modern domesticity – the kids, the Girl Scout troop. She’s even a nurse, an occupation historically associated with nurturing women. Like the woman in the editorial, Joy also became addicted iatrogenically. Perhaps the reason Joy seems so ordinary, or familiar, when we hear about her story is because there have always been women who became addicted to opioids the “right” way, just as there have always been those who became addicted the “wrong” way. Although at first glance Joy’s story shocks because it seems to defy archetypes about opioid addiction, historical analysis suggests that there have always been the dueling, interdependent molds of legitimate and illegitimate addiction in our conception of drug addiction. These tropes did not emerge during the Progressive Era-origins of the war on drugs. They’re much older. As the 1833 appeal in the Boston Medical and Surgical Journal illustrates, there have always been the “right” and the “wrong” kind of addicts. Notes Opana is so addictive that on June 8, the FDA took the unprecedented measure of requesting that drug manufacturer Endo Pharmaceuticals pull the drug from the market, after years of expert warnings. This extraordinary step was the first time the FDA has asked a pharmaceutical company to pull an opioid from pharmacy shelves as a public health measure. As the authors of this study point out, the cause of addiction is tough to measure, and various studies estimate that the iatrogenic addiction rate in the U.S. stands between one and twenty-six percent. Dan N. Longo, Nora D. Volkow, and A. Thomas McLellan, “Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies,” The New England Journal of Medicine 374, no. 13: 1269. DOI: 10.1056/NEJMra1507771. For further analysis of iatrogenic addiction rates see: Gillian A. Beauchamp, Erin L. Winstanley, Shawn A. Ryan, and Michael S. Lyons, “Moving Beyond Misuse and Diversion: The Urgent Need to Consider the Role of Iatrogenic Addiction in the Current Opioid Epidemic,” American Journal of Public Health 104, no. 11 (November 2014): 2023-2029. See also: David S. Musto, “Iatrogenic Addiction: The Problem, Its Definition and History,” Bulletin of the New York Academy of Medicine 61, no. 8 (October 1985): 705. See also: Beauchamp et al., “Moving Beyond Misuse and Diversion,” 2023. David T. Courtwright, Dark Paradise: A History of Opiate Addiction in America, Enl. ed. (Cambridge, MA: Harvard University Press, 2001), Chapter 5: The Transformation of the Opiate Addict, especially 122-3. See also: Caroline Jean Acker, “From All Purpose Anodyne to Marker of Deviance: Physicians’ Attitudes Towards Opiates in the US From 1890 to 1940, in Roy Porter and Mikulas Teich, Drugs and Narcotics in History(Cambridge, UK: Cambridge University Press, 1995), especially 123-4. See also: Musto, “Iatrogenic Addiction,” 705, and David T. Courtwright, “Preventing and Treating Narcotic Addiction — A Century of Federal Drug Control,” The New England Journal of Medicine 373, no. 22: 2095-2097. For an excellent account of narcotic addiction maintenance programs in the early twentieth century, see: David T. Courtwright, “The Hidden Epidemic: Opiate Addiction and Cocaine Use in the South, 1860-1920,” (1983), History Faculty Publications, Paper 3. For an introduction to this idea, see: Cynthia Eagle Russett, Sexual Science: The Victorian Construction of Womanhood (Cambridge, MA: Harvard University Press, 1989). Anonymous, “Opium Eating,” Boston Medical and Surgical Journal, September 4 1833, 66. Ibid. (Italics my own.) Ibid. This article originally appeared on Nursing Clio. Featured image courtesy of Library of Congress.