Research Paper by Terri Fisher
Abstract
This paper discusses the history of opioid addiction. Historical content includes recorded information pertinent to current trends. The impact on the individual, family, and society is also included. Relevant societal and cultural issues are discussed as they relate to opioid addictions. Intergenerational patterns as they relate to opioid use and perseveration of its use are included. It concludes with the effective use of family therapy to overcome opioid addiction.
The History of Opioid Use
Brownstein (1993) quotes Homer as he describes opium in The Odyssey; “Presently she cast a drug into the wine of which they drank to lull all pain and anger and bring forgetfulness of every sorrow” (p. 5391). This reference to opium dates back to the ninth century B.C. Opium and its derivatives have a long and infamous history throughout the centuries. It is now included in the drug category of Opioid in the DSM-V (2014). Heroin is also another opioid substance included within the category.
Opium comes from “opos or the Greek word for juice” (Brownstein, 1993, p. 5391). In fact, the juice or liquid comes from the unripe seedpods of the opium poppy after the pod is broken. Duarte (2005) indicates that opioid drug derivatives “have been called narcotics, hypoanalgesics and narcoanalgesics, which are inadequate terms for including other sleep-inducing drugs” (p. 2). Additionally, opioids produce a feeling of euphoria. Sumerians, who lived in the part of the world that is now Iraq, used to call opium “gil, the word for joy, and the poppy hul gil, plant of joy” (Brownstein, 1993, p. 5391).
Other historical references are noted in Egyptian tombs in the 15th century B.C. Duarte (2005) notes, “The Ebers Papyrus describes a blend of substances, among which opium, were effectively used to sedate children” (p. 2). Even as late as the 1980s, physicians were prescribing paregoric which contained opium as a way to alleviate the symptoms of colic and other chronic digestive conditions in young children (Juurlink and Dhalla, 2012). This application was also noted in the Ebers Papyrus as “a remedy to prevent the excessive crying of children” (Brownstein, 1993, p. 5391).
Duartes (2005) notes several references to the drug in Greek and Roman historical accounts of their Gods. Additionally, this translated to the Arab world in the ninth century where opium was used to treat a variety of ailments and as a form of anesthesia during surgical procedures. According to Duartes (2005), “During the Golden period of the Muslim civilization, Arabs have mastered India Ocean trade and have introduced opium in India and then in China, where it was called o-fu-yung” (p. 4). In China, opium was widely used as a way to control diarrhea for over one thousand years.
According to Duartes (2005), a Swiss physician named Paracelsus, “reintroduced opium for medical use in Western Europe” (p. 4). This occurred during the fifteenth century. Brownstein (1993) credits a German pharmacist assistant by the name of Sertuner for isolating the active ingredient of Opium. In 1806, “Sertuner isolated the active ingredient in opium and named it morphine after the god of dreams, Morpheus” (p. 5391). These results were published in the Journal of Pharmacie where he reported the discovery of an acid called meconic acid” (Duarte, 2005, p. 4). Sertuner decided that he should test the new drug morphine on himself to discover its active properties. This is one of the most articulated references to the addictive properties of morphine: “I consider it my duty to call the attention to the terrible effects of this new substance, so that a calamity may be prevented” (p. 4). Unfortunately, Sertuner’s plea was not heard.
The government of China was also alarmed by this drug. China became so concerned about the effects of opioid drugs that it attempted to limit trade related to opioid drugs. This was to stem the tide in coastal provinces where entire adult populations became dependent on the drug. Juurlink and Dhalla (2012) elaborate, “Government officials became so concerned not only about public health but also about the impact of opium use on the economy. Their attempts to limit the opium trade eventually led to the Opium Wars (1839-1842 and 1856-1860), both of which were won by Britain” (p. 394).
The American civil war contains some of the first wide spread uses of opioids. Duarte (2005) notes, “The American Civil War has created major opportunities for the massive use both of oral opium and subcutaneous morphine in soldiers wounded in combat and, as a consequence, there were records of several cases of physical dependence generating a social problem for the US” (p. 6). These same concerns were noted with British soldiers fighting in the Crimean War and Prussian soldiers in the 1870 war between France and Germany.
Concepts such as tolerance, psychological and physical dependence, including addiction were not widely discussed in the twentieth century (Duarte, 2005). It was during this time that a withdrawal syndrome was discussed to describe the discontinuation of the drug. It was at this time that “Addiction was defined by the World Health Organization as a state of periodic or chronic intoxication, noxious to individuals and society, produced by the repeated use of a drug” (p. 6). The harmful effects of the drug had been previously noted by Sertuner. Society seems to pursue that which is unhealthy once it is discovered despite the evidence that cautions against that pursuit.
Kreek and Vocci (2002) bring to light the mortality aspect of the drug. This has been chronicled since the 1940s. This set the stage for research that could stop the trend. Additionally, “a resurgence of heroin addiction in the 1960s prompted clinical researchers to search for a long acting, orally active opiate agonist that was capable of reducing or eliminating withdrawal signs and symptoms, reducing drug craving, and normalizing physiological function” (p. 94). This research lead to the development of methadone and other synthetic opioids.
In 1939, “meperdine, the first totally synthetic opioid, was introduced, starting a series of phenylpiperidine-derived drugs (Duarte, 2005, p. 7). This research was also being conducted in Germany. During World War II, methadone was first synthesized to combat the effects of opioid drug addictions with soldiers. Other synthesized drugs followed during the fifties and sixties. According to Kreek and Vocci (2002), “The Nixon White House supported the expansion of methadone treatment and worked with the FDA to develop the 1971 regulations governing the use of methadone in the treatment of heroin addiction” (p. 95). This was followed by the 1974 act passed by the U.S. Congress, which established the Narcotic Addict Treatment Act. This act “required annual registration of physicians and treatment centers, and specified treatment standards were the responsibility of Health, Education, and Welfare” (p. 95).
The Modern Day Scam
During the 1960s and 1970s, the use of opioids was still wide spread in cases of acute conditions, at the end of life, and for postoperative patients (Juurlink and Dhalla, 2012). It was during the late 1980s that widespread use of opioids for the use of noncancerous and non-acute conditions became common practice. “It was not until the late 1980s and, in particular, the 1990s that opioids became a commonplace element of therapy for patients with chronic pain” (p. 394). This also prompted research into new opioid formulations that became known as Oxycodone, which was quickly followed by OxyContin.
Perhaps one of the most interesting results of these new drug formulations is with the promotional activities related to the release of OxyContin in 1996. OxyContin is a sustained release version of Oxycodone. Upon its introduction, the product was vigorously marketed as a safe and effective way to help patients manage pain. It was also touted as having very low addictive properties. Van Zee (2009) notes, “The promotion and marketing of OxyContin occurred during a recent trend in the liberalization of the use of opioids in the treatment of pain, particularly for chronic non-cancer related pain” (p. 221). In fact, Purdue Pharma, the company which produces OxyContin, “conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California . . . physicians, pharmacists, and nurses attended these all-expense paid symposia where they were recruited and trained by Purdue national speaker bureau” (p. 221). Over five thousand of these professionals were trained to teach their cohort about this new and safe drug. These medical professionals were picked based on research noting the areas in which opioids were being widely prescribed.
This massive training effort was also supported by an increase in sales staff (Van Zee, 2009). Massive incentive bonuses were paid to its doubled sales force. A physician list of over 94,000 doctors was generated. The sales staff was then instructed to deliver patient starter coupons to the physicians. These coupons “provided patients with a free limited-time prescription for a 7 to 30 day supply” (p. 222). Van Zee states, “By 2003, nearly half of all physicians prescribing OxyContin were primary care physicians” (p. 222). This represented a shift in the treatment of pain from surgical, pain monitoring, and emergency physicians to primary care physicians; the primary work force in managed care systems.
A societal shift occurred that created a market that previously had not existed. Van Zee (2009) notes that during this time Purdue Pharma executives continued to claim the safety and efficacy of OxyContin. In fact, “Purdue claimed that the risk of addiction from OxyContin was extremely small” (p. 223). Sertuner may have disagreed if he would have been alive to discuss the merits of opioids. In 2007, “Three company executives pled guilty to criminal charges of misbranding OxyContin by claiming that it was less addictive and less subject to abuse and diversion than other opioids, and will pay $634 million in fines” (p. 223). This seems a very small price to pay when compared to the effects the drug had and continues to have on family, societal, financial, and ecological concerns.
According to McHugh, DeVito, Dodd, Carroll, Potter, Greenfield, Connery, and Weiss (2013), “The number of opioid prescriptions and the abuse rate of prescription opioids have increased greatly in recent years . . . consistent with these new trends, mortality rates, societal costs, and treatment seeking related to prescription opioid use disorders have increased substantially” (p. 38). This is a societal patterns as well as an addiction pattern. Lewis (2014) notes that patterns of use create addictions. In fact, the very act of going to the doctor monthly, having your pain level monitored, leaving with your handy prescription of legally acquired drugs, then going to the pharmacy where you provide the financial reimbursement for your drug of choice is similar to the drug seeking activities of any individual who regularly seeks out his dealer, makes a time and place for the meet, handles the financial transaction, then leaves with her drug. The first difference in the pattern lies in the shift from non-acceptable to acceptable behavior. The second lies with an insurance company that helps pay for the drug.
Vulnerable Populations
Few question their doctor; after all, he/she took the Hippocratic Oath that provides for ethical treatment. Your own doctor would not allow you to be treated in a harmful manner. We are brought up to culturally accept the direction of a physician. Women may be particularly sensitive to the role of a doctor. Other factors also add to the gender difference such as a pregnancy, a situation that includes domestic violence, or a woman who is homeless. Heil, Jones, Arria, Kaltenbach, Coyle, Fischer, Stine, Selby, and Martin (2011) state, “Licit and illicit opioid dependence during pregnancy is often complicated by a multitude of other factors, including low socioeconomic status, poor nutrition, lack of parental care, family instability, interpersonal violence, homelessness, psychological problems, and other drug use” (p. 199).
Another population of individuals that is particularly vulnerable to opioid addiction is the elderly. Lofwall, Brooner, Bigelow, Kindbom, and Strain (2005) state, “The continuing shift to an older age distribution in the United States will significantly impact the entire health care system including substance abuse treatment services . . . substance use problems are frequently overlooked and are often associated with significant medical and psychiatric morbidity and mortality, and among older adults (age 60 and over) have been declared an invisible epidemic by the Substance Abuse and Mental Health Services Administration” (p. 265).
Lofwall, et al., (2005) note, “Consistent with previous studies of psychiatric comorbidity in opioid dependent samples study participants had high rates of many lifetime and current psychiatric diagnoses compared to general-population samples” (p. 270). This begs the question of how effective we are as a society in providing psychological and medical treatments concurrently. As individuals move through life stages and change, do we provide a level of care that addresses the needs of individuals in relation to their family stages? MGoldrick, Carter, and Garcia-Preto (2011) state, “In families where addictions and AIDS have led to parents being unable to take care of their children, grandparents may continue to be caretakers way past midlife” (p. 249). The long terms effects established by ineffective patterns create a generation of elderly individuals who are particularly vulnerable to the stressors in life. In a managed care system that gives perhaps ten minutes to discuss a plethora of needs, it would be easy to prescribe a pill that has a history of helping relieve both physical and emotional pain without solving the underlying issues. This creates a pattern of societal demands, which creates epic failure to address needs adequately.
Conclusion
Research clearly shows that addressing needs from a systemic perspective, and incorporating family concerns, has a measurable impact when dealing with opioid addiction. Comisky (2013) elaborates, “Opioid addicted parents within methadone treatment who underwent a family focused intervention reduced their level of opioid use, improved their coping skills, and held more family meetings to discuss family fun” (p. 90). In fact, including the family provides the stability for each member to heal together without the trauma of separation. Rowe and Liddle (2003) state, “Process research focuses on the nature and sequences that determine important change events in family therapy, or those interventions that lead to successful resolution of problems or relational shifts within the family” (p. 105). Addressing the needs of families who have members with opioid addictions should include a process that focuses on the patterns and behaviors that created intergenerational patterns of dysfunction. It should also provide support for the resiliency of the family to withstand societal pressures while honoring the family as a unit that can heal.
References
Brownstein, M.J. (1993). A brief history of opiates, opioid peptides, and opioid receptors. Procedures of National Academy of Science, 90, 5391-5393.
Comisky, C.M. (2013). A 3 year national longitudinal study comparing drug treatment outcomes for opioid users with and without children in their custodial care at intake. Journal of Substance Abuse Treatment, 44, 90-96.
Duarte, D.F. (2005). Opium and opioids: A brief history. Revista Brasileira de Anestesiologia, 55(1), 1-11.
Heil, S.H., Jones, H.E., Arria, A., Kaltenbach, K., Coyle, M., Fischer, G., Stine, S., Selby, P., and Martin, P.R. (2011). Unintended pregnancy in opioid-abusing women, Journal of Substance Abuse Treatment, 40, 199-202.
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Lofwall, M.R., Brooner, R.K., Bigelow, G.E., Kindbom, K., and Strain, E.C. (2005). Characteristics of older opioid maintenance patients. Journal of Substance Abuse Treatment, 28, 265-272.
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McHugh. R.K., DeVito, E.E., Dodd, D., Carroll, K.M., Potter, J.S., Greenfield, S.F., Connery, H.S., and Weiss, R.D. (2013). Gender differences in a clinical trial for prescription opioid dependence. Journal of Substance Abuse Treatment, 45, 38-43.
Rowe, C.L., and Liddle, H.A. (2003). Substance Abuse. Journal of Marital and Family Therapy, 29(1), 97-120.
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