Narcotic Addiction in America

In August 2017, President Donald Trump announced a new strike in America’s everlasting war on drugs. Talking about the “opioids crisis” [1], he declared: “nobody is safe from this epidemic that threatens young and old, rich and poor, urban and rural communities. Everybody is threatened.” He went on to remark that drug-related prosecutions and convictions had receded in recent years, allowing addiction to flourish once again and overdoses to multiply, and to shift the blame for the ‘deadly path’ America was on to the previous administration’s leniency towards both abusers and “dealers poisoning our communities”. He finally promised a strong response, involving better education – in his own words, teaching young people that “drugs are no good, really bad for you” [2] – and tougher sentences – up to and including the death penalty for drug dealers. This looks, to all intents and purposes very much like a return to the brutal 1980-90s Rockefeller era [3] and Nancy Reagan’s deeply inadequate “Just Say No” campaign.

While President Trump’s stance on the matter is hardly surprising – it is, after all, in line with a long-standing American tradition of repressive, racially-biased and tragically ineffective anti-drug policies – it cannot fail to baffle anyone who knows anything about either the science of addiction or the history of narcotic control in the U.S. For a country that has struggled for over a century, much longer and harder than any of its European counterparts, with the question of substance abuse and control, for a nation so deeply haunted by the specter of addiction and its supposed relation to crime and decadence, America seems to have a remarkably loose grasp on the concept and a very short memory when it comes to implementing measures meant to curb the dangers of excessive narcotic consumption. Interestingly, the 2015-2018 epidemic has prompted a slightly more compassionate response in the media and public discourse, presumably because it is especially visible among young to middle-aged, middle-class white people (the increase in drug-related deaths being particularly steep among those aged 55-64), thus breaking with the stereotypes of both the teenage hippies of the counter-cultural years and the crack-cocaine and heroin-riddled big city ghettoes. The latest epidemics has also given way to a new salve of sociological and scientific studies focusing on the possible reasons for the surge, from the depressed job market to a new American existential crisis. In early 2018, health economist Christopher J. Ruhm, in an extremely thorough study, concluded that the increase in overdoses was hard to correlate with “economic despair” as it had been heavily suggested by different media sources, but was rather due to an underlying prescription drug problem: in other words, a large part of this newly visible addicted population had contracted an opiate problem because they had been legally prescribed opiate-based medicine, especially painkillers (Ruhm, 41-44).

Rhum’s study was widely cited and reviewed, including by the general press – The New York Post and the Economist, for example, dedicated several pages to its discussion. The most arresting fact in this development, however, was perhaps how surprising Ruhm’s findings seemed to be for most reviewers – as if no one reporting on the opioids crisis had seriously considered a possible correlation between regularly consuming opiate-laced medicine and developing a potentially lethal addiction to it. This, fortunately, is not quite true. Many scientists, community leaders and general publications in America have been vocal on the dangers of prescription drugs for years, with a renewed interest in pharmaceutical companies’ dealings since the beginning of the epidemic. Moreover, physicians’ realization that opiate addiction was often contracted during a lengthy medical treatment dates back to the 19^th century. It seems, however, that much about addiction has yet to permeate the American mind, which betrays an alarming absence of perspective regarding a long and complex history between the medical sphere and narcotic addiction, as well as a troubling lack of understanding about the mechanisms of chemical dependence.

The desire to deny that narcotic addiction is a disease that can easily be contracted by most exposed individuals and to instead blame the condition solely on addicts is nothing new. They are still frequently painted at best as fragile, weak-willed creatures, unable to face hard times or easily manipulated by evil (and generally foreign) forces who would benefit from their downfall, and, at worst, as criminal deviants endangering the social and moral integrity of America. Where the addicted populations fall on this wide spectrum remains heavily dependent on their ethnicity and social status, two factors that have consistently appeared as the most decisive in the fluctuations of public opinion on the matter over the course of the last century.

The redefinition of inebriety as a medical condition

Understanding the ambiguous status of narcotic addiction in America, regarded sometimes as a disease, sometimes as a deviance and often as both, requires a close look at how the concept of addiction itself came into being. The first real “drug abusers” – that is to say regular and excessive narcotic substances consumers [4]– appeared in the mid-19^th century. The phenomenon can be described as both a factual appearance (most narcotics, even opiates, were not readily accessible in the US before the early 1800s, meaning that continuous intoxication was extremely rare, and addiction could hardly be developed or recognized) and as the conceptualization of a new object. Addicts came into existence not only because they effectively multiplied due to the increased availability of opiates, but also because they were identified as such – isolated, named and studied by different discourses in the press, among legislators and within the medical community.

Journalists and preachers were perhaps the first to comment upon the phenomenon in big cities. They were initially concerned with the “yellow peril”, Chinese immigrants flooding the US and bringing opium dens with them, with barely-veiled intentions to corrupt upstanding citizens and steal their women, creating a degenerate population of “deviants, devils and wanderers”, as a New York Times editorialist called the newly formed opium-smoking community in 1882. Gambling, prostitution and low morals were typically associated with recreational drug users. In most states, steps were taken to regulate immigration and monitor opium dens on moral grounds, but, save for a few agitators, most considered drug addiction in itself a minor vice, practiced by a handful of low-class citizens and foreigners. The figure of the dangerous junkie would not emerge before the 1910s, with the first heroin epidemic (Courtwright, 2001, 85-110). Until then, opium addiction, while regarded with disdain, seemed significantly less worrisome than excessive drinking and this particular type of deviance was often used to denounce greater evils such as immigration, debauchery and smuggling.

The medical profession, however, developed a keen interest for this new occurrence early on and had a very different outlook. Many physicians gradually became aware that they had accidentally caused an “habituation” problem in patients or even in themselves by indiscriminately administrating opiates, which had come to be an essential element of the physician’s “little black bag” in the first decades of the century. This discovery would lead, in the second half of the 19^th century, to the conceptualization of chemical dependence or “inebriety”.

In the process of elaborating the medical discourse of addiction, nothing is quite as important as looking closely at terminology. The way both scientists and the public referred to drug users in the 19^th century is an excellent indicator of how they were perceived and how that perception slowly evolved with time. The most popular words we encounter in 19^th century non-medical sources, especially in the press, but also in pamphlets and works of fiction, are mostly slang: drunkard [5], wino, soaker, hard case, junkie, dope fiend, pipe hitter, snorter – they are both derisive and descriptive and they reduce the addict to his or her consumption of the drug, denying them any other characteristics but that of a user. Terms that would become fashionable again in the 20^th century, such as alcohol, drug or substance abuse, can also frequently be found in legal documents and police reports. While they appear more neutral, the idea of “abuse” springs from religious and moral conceptions of excess as the root of severe drug problems. As addiction specialist William White states: “they define the locus of the problem in the willful choices of the individual, denying how that power can be compromised, denying the power of the drug” (White, 4), and in doing so, expunging the culpability of any other party. Temperance literature, on the other hand, usually advocated for complete alcohol and opioid prohibition and tended to insist on the “evil”, “poisonous” substance and on the weakness of its “victims”, representing addiction as a form of “disease of the will” (Hickman, 22-25).

The appearance of specific clinical terms to refer to either the state of intoxication or those who consume intoxicants, and their subsequent popularization outside of the medical sphere, however, is especially relevant: it marks a slow but steady appropriation of the matter by the medical profession, subtly transferring the question of addiction and addicts into the hands of physicians. In the earliest published medical literature, before 1850, references to a “trance state”, “drunkenness” and “substance poisoning” can be found, but some distinctly “medical” idioms began to emerge by mid-century and slowly colonized scientific articles and reports in the late 1860s. Terms ending in –ism, denoting a specific and systematic habit, and –mania(c) indicating obsession or compulsion, spread quickly in medical publications (Tracy & Acker, 33-55). It began with “alcoholism” [6], a word used to describe chronic alcohol intoxication and to separate “normal” drinkers from “pathological” drinkers, effectively identifying and differentiating acceptable and regular behavior (moderation, discipline) from vice (excess, loss of control) – the beginning of the rhetoric of addiction. This particular terminology was soon to be applied to narcotic consumption as well: new words such as opiomania, morphinomania, or the rarer narcomania were coined to classify new pathologies, subcategories of the larger concept of what most American physicians would soon refer to as “inebriety”. This term, by the 1890s, had acquired a markedly scientific connotation and the approval of most in the American medical community, before being gradually replaced by “addiction” at the turn of the century.

While those two words were not modern inventions – both are derived from Latin roots, inebriare, meaning “to intoxicate”, and addictionem “penchant” or “devotion”, and occurrences in the English language have been noted since the late 16^th century – it was not before the last decades of the 19^th century that they became the generic medical designation for what we call today “chemical dependency” [7]. That evolution marked an actual revolution in the approach of drug use and users: the beginning of the disease theory of inebriety.

Introducing the disease theory: from inebriety to addiction

Pinpointing precisely the beginning of the history of narcotic addiction in the U.S. is an impossible task. However, the Civil War has frequently been described by both physicians and historians as an unprecedented turning point in the development of opium addiction. Indeed, a number of previously “sober” soldiers, had come back from the field battling a new enemy: opium or morphine dependency, contracted iatrogenically – as a result of a prolonged exposure through medical treatment [8]. As doctors’ and veterans’ memoirs relate, opiates had been generously distributed to the wounded and the increase of opium and morphine abusers among their ranks led a few prominent members of the medical community to investigate this intriguing phenomenon. Concurrently, evolutions in medical practices and pharmaceutical products had increased opium consumption per capita at least threefold between 1850 and 1870, and the concomitant rise of addiction to opiates among civilians, especially middle-aged women in rural areas (to whom morphine was heavily prescribed on account of “female troubles”), convinced the new specialists of this budding field that drug craving could not simply be a moral flaw, but had very real physiological and neurological roots (Courtwright, 35-60).

Thus, the “disease theory of inebriety” began to spread within the American medical community. It was first popularized in the 1870s by one very influential medical society: the American Association for the Cure of Inebriates (AACI). Created by Dr. Joseph Parrish and fourteen other physicians who supervised the main “inebriate homes” – recently created institutions providing shelter and often medical treatment to those struggling with inebriety – in the country, the association was at the core of the Inebriety Movement, a national impulse designed to recategorize alcoholism and narcotism as diseases instead of vices. Their Quarterly Journal of Inebriety, which would run from 1877 to 1914, was the main addiction-related publication in the US and achieved international notoriety beginning in the 1880s, influencing similar movements in Canada, Great Britain and Germany.

Despite debates and dissensions on the nature of chemical dependency within the medical community itself and between the Inebriety and Temperance movements, the definition of inebriety put forward by the AACI became widely accepted by the end of the 1880s. It is maybe best described by one of the leading experts in the field, Dr. Norman Kerr, who diagnosed it as a “constitutional disease of the nervous system characterized by a morbid craving for intoxicants.” (Kerr, 18) While there was no consensus on the etiology or treatment of the affliction, even among the members of the AACI, most of them defined it a chronic affliction of the brain, possibly hereditary, particularly difficult to treat because it affected both the body and the mind of the patient, depriving them of their strength and courage – a true “disease of the will”. It was believed that it could be treated with self-discipline, meaning a lifelong, total abstinence, and a series of rather bizarre remedies, including techniques as diverse as “gold cures”, Turkish baths, strychnine [9] and moral therapy, which profoundly divided addiction “experts” for decades (Crothers, 130-132).

More importantly still, the conceptualization of inebriety led to the discovery of addiction itself. Although the two terms were often used indiscriminately in medical literature at the end of the 19^th century to refer to the ailment of the drug user, a fundamental distinction began to emerge: inebriety on its own referred to a state of drunkenness and to the symptoms of the disease – loss of control, depression, cravings. “Addiction”, however, suggested that the substances absorbed did not merely cause a temporary state of intoxication, but “polluted” the body on a long-term basis and changed its inner balance, its chemistry, throwing hormones and neurons in disarray and making the continuous consumption of the drug necessary for the addict to function “normally” (Mattison). This meant that drug cravings in those individuals were not about desire or pleasure, but survival. It was therefore necessary to wean addicts off their drug gradually in order to enable their system to detoxify properly – or, in the most extreme of cases, to maintain them indefinitely on low doses of morphine [10]. Indeed, physicians progressively began to consider that brutal withdrawal was dangerous and counter-productive and that what would later be called “withdrawal symptoms” were not manufactured, nor was the addict’s sufferings a staged performance destined to produce compassion or alarm in order to be given more drugs. It was deemed to be an actual physical response to the deprivation of the narcotic substance, one that could turn out to be lethal if not attended to properly and treated slowly (Hubbard, 42-50, Crothers 1902, 175-196).

By the turn of the century, the outlook on opiate addiction itself had changed. If the disease theory was not embraced by everyone in America, especially not by hard Prohibition advocates, most of the medical community was now convinced that addicts were victims rather than sinners, diseased individuals rather than malevolent people. Above all, many believed that they could be cured. From the 1880s to 1915, with very little jurisdiction enacted to define the status or fate of opiate users, American physicians attempted to draw struggling addicts into the medical sphere, both to study their affliction and to benefit from their patronage. They initially encountered little resistance from the authorities: addicts were a recurring problem for state-run institutions such as insane asylums or prisons, which did not have the means to efficiently deal with them, and the perspective of unshouldering that burden was generally greeted with few misgivings.

The Stigma of Disease: “those who would be saved”

The status of the addict as a diseased person, however, would prove to be a controversial and ambiguous over the first few decades of the 20^th century. On the one hand, heated debates between those who argued for the complete prohibition of both alcohol and opiates and physicians who defended maintenance grew after 1900. Stating that the disease theory of inebriety had no physiological basis allowed the former to call for teetotaling [11]without seemingly endangering the lives of addicts. If addiction, and therefore withdrawal, was a bona fide disease, then Prohibition was impossible to establish. The first “heroin epidemic” in the 1910s – another iatrogenically contracted addiction, since heroin had been ironically marketed as a pharmaceutical, non-addictive alternative to morphine since the late 1890s – involved a different population of addicts (young, working-class, urban black and white men) and would give them ammunition to campaign against the image of the “sick victim” that physicians promoted, especially after one of the most prominent hypotheses in the disease theory, the immunochemical theory, was proven wrong.

Temperance forces did not hesitate to play on respectable people’s feeling of insecurity and on racial tensions: the “Cocaine Negro”, for example, committing “murder and insanity” under the influence of the drug became a popular reference in the South (The New York Times, 1914). Concurrently, anti-immigration leagues invoked once again the specter of the opium-smoking, woman-stealing Chinese immigrant to ensure the general public would readily associate opiates with crime.

These mutations in the addict population also caused dissensions within the medical community itself. Many physicians were beginning to feel frustrated by this new type of unruly “patient”, who would frequently ignore medical advice and elude treatment. By the end of the war, they were also growing disappointed with their own unsuccessful attempts at curing opiate addiction. They were not, however, quite ready to abandon their position: one way to circumvent the contradictions inherent to their hypotheses was to argue that the disease theory of addiction was not necessarily applicable to all cases of drug abuse. While some physicians – especially in New York where a large community of addiction specialists resisted well into the 1920s – would maintain that all addicts were sick and in need of medical attention, many more were deeply influenced by the ideological framework of their time and their discourse on the issue tended to support the existing social order more often than not. Although medical language generally excluded a critical appraisal of the social context, medical diagnosis and practices were most certainly not immune to it. T.D. Crothers, a pioneer of addiction studies research in the late 19^th century, called to “those who would be saved” to seek treatment with him, implying that those who did not were simply incurable in the first place (Crothers, 46-48). His approach suggested that a “scientific” hierarchy of addicts could be established, one that unsurprisingly reflected a prejudiced moral and social classification of patients along the lines of class, race, gender and personality to determine who was actually capable and worthy of being cured (Courtwright, 33-60, White, 12-21).

Once again, the chosen terms and their specific definitions are enlightening: morphinomaniac, for example, meant morbid craving for morphine while morphinism was defined as the disease caused by morphine consumption (Kane, 1881, 41). Both concepts quite evidently related to the same condition but were often not used to refer to the same type of addicts. There had always been, for instance, a remarkable dichotomy in the treatment and consideration of the aforementioned iatrogenic morphine addicts, mostly respectable middle-aged, middle-class women living in rural areas, who had been prescribed opium and morphine to deal with their feminine troubles, and opium-smoking drifters, prostitutes, Chinese immigrants, gangsters and, at the beginning of the 20^th century, inner-city heroin junkies. The former were considered victims of either medicine or unfortunate heredity, afflicted with a treatable disease, while the latter had become addicted through their own debauchery and were probably unredeemable, for they lacked the moral qualities and stable background for future abstinence (Lindesmith). Some physicians considered that inebriety was only a disease when it caused “normal” people to lose control over their mind and body to the point that they needed to continue consuming the drug to maintain a regular lifestyle but derived no pleasure from it (Kolb), and a vice undeserving of medical care, if practiced by people who took narcotics for recreational purposes – sometimes deemed to be “psychopaths” [12].

It effectively created two subtypes of addicts: the good ones and the bad ones, those who were sick yet could be saved, and those who had always been lost.

The specter of degeneration

Finally, medicine had developed another theory concerning addiction that would prove to be particularly worrisome for the future perception and treatment of addicts. With the discovery of genetics and heredity, the specter of degeneration was looming over 19^th century America. Nervous system functioning was associated with people’s moral behavior, as well as with their social position. Influenced by Cesare Lombroso’s criminal phrenology, American physicians tended to believe that a person afflicted with a form of physical or mental degeneracy would often decline from moral normalcy towards “abnormal, instinctive, animalistic depravity” (Aurin, 419). Some people were considered “degenerates” – genetically altered human beings, whose heredity was a source of negative traits that might be passed on to their own children. In the early stages of the addiction theory, the affliction was often believed to be hereditary, or its appearance was seen as a symptom of a degenerate ascendance.

Genetic sciences were still in their infancy, and some of the specialists’ most firmly-held beliefs have long since been disproved, but most physicians who wrote on the subject in the late 19^th and early 20^th centuries attempted to understand why certain individuals were more susceptible to addiction than others, and sought to explain this “predisposition” through their genetic heritage rather than social and historical context (Kolb). The idea of degeneration was an evil that greatly preoccupied not just the medical community, but the American population at large. The concept is familiar: it stipulates that the weaknesses (moral, mental and physiological – the distinction was not always clearly established) of one generation was not only passed on, but also produced increasingly weaker generations, although the link was not always apparent. In the case of drug addiction, it was thought that one who had overindulged in alcohol, for example, would likely produce an alcoholic child who, in turn, would give birth to a drug addict (Kerr, 185, 608). All social classes and ethnic groups could suffer from degeneration, but with regards to inebriety or addiction, the diagnosis would vary depending on who was treated: the inherited inebriety of the upper and middle-class morphine addicts, for example, would be linked to neurasthenia or epilepsy, while it would be diagnosed as the fruit of mentally deficient parents in the lower classes, particularly the Irish. Black Americans were regarded as easily addicted to opiates and cocaine, but not to alcohol, while Chinese immigrants presented the opposite disposition. Once again, the pervasiveness of social and racial prejudice in the medical discourse is apparent. Diagnosis frequently ignored other “social” factors which could have perhaps more convincingly explained away the differences observed – such as the greater hold of the temperance movement over Black populations in the South or the much higher rate of “nervous disorders” (many of which would later be identified as depression) in non-working women. Neurasthenia, a theory of “nervous exhaustion” developed by George M. Beard in the 1860s, was also believed to be a genetic factor in the development of addiction but rarely the actual cause of drug abuse.

The hereditary status of addiction was a somewhat double-edged sword for addicts. On the one hand, it presented them as victims of their bloodlines, unable to control their cravings, but on the other, it made them appear as incurable and cast a doubt on their ability to produce healthy American children. Interestingly, a few articles stated that female opium addicts were likely to become barren. A young activist interviewed by The New York Post commented in 1889: “Sterility is not just a punishment from God. It’s salvation for the rest of us!”. She was not the only one to believe that “defectives” and “degenerates” should not be allowed to reproduce. [13]

Since the 1880s, many groups in the US had been developing eugenic discourses and strategies, intended to better the American race. Although they are rarely mentioned in today’s studies, narcotic addicts were high on the list of those who should be eliminated at all costs and perhaps even undergo forced sterilization, despite the outrage it initially caused among the physicians who specialized in their rehabilitation. In the early 20^th century, many sterilization procedures were conducted without the patients’ knowledge, making them impossible to trace. It is therefore difficult to establish how many of the “dangerous inmates” of state prisons and hospitals selected for the surgery were drug addicts. Many physicians treating addicts also advised their patients not to try and have children, lest they suffer from the same unfortunate condition. At any rate, the threat of degeneration, of genetic corruption by unfit people such as substance abusers, was one scientific theory that prohibition advocates and partisans of tough narcotic regulations could get behind. Narcotic addicts endangered American society not only with their immoral behavior, but also with their potential reproduction. The disease theory, perhaps accidentally, introduced the notion that there was something inherently and inalterably off in addicts: while deconstructing the original stigma of moral unsoundness attached to the first generation of addicts, the medical community had created a battery of new fears concerning addiction: was it curable? Was it transmissible? Was it a danger to the American race? And above all: who really deserved to be treated?

By 1920, while the disease theory had not been entirely discredited, priorities had changed. In the public’s eyes, medicine had failed to cure addiction – worse, it had enabled it for decades and America was now more than ever open to the risk of moral and genetic corruption. In that same decade, the Harrison and Volstead Acts, by virtually draining the supply of legal narcotics, marked the beginning of a new era of federal substance control and the clear criminalization of addicts, who became more likely to be imprisoned than properly treated until the 1970s.

Conclusion: a new deal for the American drug addict?

Since the 19^th century, the status of the American drug addict has been seemingly submitted to a cyclical evolution of public perception. One hundred and fifty years ago, addiction began its transformation from an almost invisible and innocuous ailment to a potential threat, and finally a public health concern – a constantly repeated sequence from the 1960s to the 2000s. The ensuing confusion regarding the nature of narcotic addiction and, by extension, of addicts, and the best ways to “deal” with the problem has consistently had catastrophic consequences on users, from human experimentation in the 1930s to mass incarceration in the 1990s. It is all the more surprising that American physicians have long attempted to fully medicalize addiction, creating, theorizing, diagnosing, and attempting to cure the disease of “inebriety”. For over a century, most of these specialists have argued that addiction was not a moral flaw, but a treatable sickness, often contracted iatrogenically.

However, while today’s international neuroscientific and medical communities seem to have reached a consensus, declaring drug addiction a “brain disease” caused by many factors but especially prolonged exposure to intoxicants [14], this paradigm has yet to be embraced by many science-skeptic institutions: politicians are once again calling for the incarceration of users, treatment centers are closing down due to defunding, health care companies refuse to insure drug users and all the while, pain-killer prescriptions and pharmaceutical companies manufacturing opiate-based medicine continue unimpeded.

Vice and disease, it seems, are not considered to be mutually exclusive notions by the American public. Depending on their racial and social characteristics, addicts have been described as innocent victims, accidentally “poisoned” and only trying to remain functional, or as criminals and psychopathic hedonists, with the 20^th and 21^st centuries hailing a string of repressive measures against them, often at the expense of their health and even their lives.

Can severe opioid addiction truly and permanently be cured today? Experts’ opinions diverge on the matter. It can, however, be treated and managed – but solely with the appropriate support not only of medical sciences, but of civil communities. The main obstacle to efficient treatment and recovery remains the underlying belief that the inception of the problem lies not with the substance or even with prolonged exposure to it (and it would therefore be counterproductive to curb the lucrative business of opiate-based medicine produced by pharmaceutical companies), but rather with the addicted persona. It is still believed that there is, in essence, something wrong with addicts, that they are “abnormal” individuals, morally, mentally, or physically deficient, who can never truly become productive members of American society – and as long as this view continues to prevail, everyone will have lost the war on drugs.