How politics and professional rivalry undermined an effective medicine

Opium was used to treat pain and other symptoms by various medical traditions for centuries. In a three-part series starting in this issue, Dr. Romayne Gallagher looks at the forces that demonized opium and its related compounds from the mid-1800s to the mid-1900s, finding they had little to do with medicine.

“Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium. . . . So necessary an instrument is opium in the hand of a skillful man, that medicine would be a cripple without it.”—Thomas Syndenham, 1680

“The use of narcotics in terminal cancer is to be condemned if it can possibly be avoided. . . . Morphine usage is an unpleasant experience to the majority of human subjects because of its undesirable side-effects. Dominant in the list of these unfortunate effects is addiction.”—L.E. Lee et al., Journal of the American Medical Association, 1941

Two completely opposite views of essentially the same medication. How did medical opinion shift so dramatically?

The influences affecting opioid use from 1870 to 1930 are many and not often based on science or evidence but on culture, domestic and international politics, social morals and religion to name the major factors. Even today, why is there so much emotion and so little science around the use of these medications?

Opium, the extracted juice of the bulb of the poppy, has been around for millennia. Sumerians writing in 6000 BC noted the domestication of the poppy. Its use in headaches and other painful conditions is noted in Egyptian, Greek and Roman texts, with the first written prescription dated 1552 BC. Toxicity from opioids was known in the 2nd century BC. Galen described the use of opioids by prominent members of Roman society on a regular basis without dose escalation. It was listed in the Canon of Medicine, used in Arabian societies at the turn of the millennium in 1000 AD. It was firmly established as a therapeutic essential by European and British physicians, as the quote from Sydenham notes.

Opium was used for a multitude of symptoms, such as shortness of breath and cough in respiratory ailments such as tuberculosis, asthma and bronchitis. Constipation was seen as a benefit, making it a major therapy in dysentery, cholera and any form of diarrhea. Its pain relief was sought for rheumatism and chronic pains, including neuralgia and sciatica. Its sedation and calming properties were used for sleep, hysteria(likely anxiety)and in some cases used to treat the mentally ill as it was seen as more humane than restraint or punishment. Opium’s ability to reduce the amount of sugar in the urine of diabetics also made it one of the only treatments available until insulin was discovered.

Compared with the other major therapies of bleeding, purging and emesis, opium must have seemed to most patients and physicians as a tolerable and beneficial therapy.

Opium was smoked in Indian and Arab societies as a recreational drug—akin to alcohol or nicotine use in our society. Both the recreational and medicinal use of opium made it a valuable trade commodity.

As colonizing nations such as Britain began to vigorously trade goods, including opium, the use spread around the world. Britain had traded opium with China for years in return for spices, pottery, china and other goods. China was never in favour of opium smoking and took a first regulatory step when the Emperor banned opium smoking in 1729. The royal ban led to a thriving black market and by 1829 China estimated that 1% of its population was addicted to opium. In 1838, the Chinese government made concerted efforts to stop the importation of opium. This resulted in the two “opium wars” between the 1840s and 1860s, when Britain forced China to accept trade in the commodity. It was well worth fighting over; opium was the most valuable trading commodity in the world in the 1830s, with $18 million of the drug being traded each year.

Europeans, particularly women and those in the upper classes, regularly used opium as a recreational drug in the 18th and 19th centuries. Since alcohol was considered an inappropriate substance for women to use, tincture of opium in sherry —laudanum—had been used regularly since the 1600s. Until the late 1800s it was not unusual for people to use opium or laudanum on a regular basis for sleep or relaxation. Local grocers, or the drug importers, openly mixed opium derivatives and sold opium to the public.

North Americans regularly used opium to help them relax after a hard day at work. In the 1800s, American entrepreneurs took opium and made it into a multitude of popular tonics, syrups and cure-alls for a multitude of illnesses. It was used for calming children(Mrs. Winslow’s Soothing Syrup), for pain(Perry Davis’s Vegetable Pain Killer)and whatever the market would bear.

This market remained unregulated until the early 1900s when the Food and Drug Act regulated the listing and labelling of products. By then opium had fallen from favour.

Much of the shift in medical use of opium occurred in the 19th century with major discoveries made in Europe.

Morphine was extracted from the opium poppy in 1806 and codeine followed in 1832. Commercially produced oral morphine appeared in the 1820s and was promoted for use in pain, other symptoms and as a substitute for those addicted to opium.

The hypodermic syringe was introduced in the mid-1850s, giving the physician the ability to administer a rapid-acting, accurately dosed agent to control pain, cough, shortness of breath, diarrhea and anxiety. This gave the doctor more control over the body of their patient and over the dose they were administering.

The list of medical indications for hypodermic morphine grew, and an 1880 treatise on the uses includes: angina, asthma, bronchitis, cholera, carcinoma, delirium-tremens, diabetes, diarrhea, emphysema, epilepsy, gastric ulcer, insomnia, incontinence, malaria, mania, meningitis, muscular spasm, neuralgia, nymphomania, pericarditis, rheumatism, shock, tetanus, uremia and vomiting in pregnancy. Considering that there was little else to offer patients with most of these diseases(acetylsalicylic acid, or ASA, was not available until 1899 and antibiotics not until 1928)the ability to have quick relief was considered a significant breakthrough.

During the 19th century in the U.S., “European-style” doctors educated at medical schools were not yet seen as the gold standard. Folk physicians with little or no established training were still quite popular and competed for patients.

Treatments such as bleeding and purging with mercury chloride and inducing emesis with tartarized antimony-—which were poisonous-—were the major therapies. The more effect a drug would have on the person, particularly the bowels, the more likely it was thought to cure the disease. Opium, with a strong effect on the bowels and with its ability to relieve pain, was invaluable. When morphine was isolated, this new scientifically derived drug was firmly within the allopathic doctor’s bag, while the more folk remedy opium was a disguised product in the natural folk remedies.

In the latter part of the 1800s there was a jockeying for position between allopathic and homeopathic physicians as well as pharmacists.

Allopathic physicians formed the American Medical Society in 1847 followed shortly by the American Pharmaceutical Association(APA). In 1858 the APA moved to restrict the dispensing of all medicines to “educated druggists and apothecaries” rather than physicians and populist doctors. The Canadian Medical Association was formed in 1867. Sir Charles Tupper, later the prime minister of Canada, served as the first president. This attempt to stake out professional territories resulted in opium and its derivatives being placed in a political sphere unrelated to its pharmacological properties.

Morphine, produced commercially by pharmaceutical companies, was the drug of choice for allopathic physicians.

Pharmaceutical companies then began to take other folk remedies and isolate the ingredients and commercially produce them. The Food and Drug Act at the start of the 20th century required that products list their ingredients and establish safety and efficacy before entry into the market. Small folk remedy producers could not compete with the pharmaceutical companies so the battle for pharmaceutical dominance was won by allopathic medicine and its supporters.

Physicians, in a bid to gain a better reputation than their folk colleagues and the patent medicine industry, began to assert themselves as keepers of the health of the people and the nation and began to persuade Canadians about the social and educational issues contributing to health. A Canadian Lancet editorial in 1886 noted that physicians “are continually making strenuous exertions in the public interest against disease in many ways, and devoting our time and talents often gratuitously to hospitals, homes, asylums, infirmaries and boards of health, etc. . . .Therefore we claim credence and confidence when our advice is given.”

Physicians also extended their role to protecting the moral and mental health of individuals and the nation. Dr. John Stewart, president of the CMA in 1905, noted in his presidential address,“We cannot treat our patient to advantage if we regard only his physical condition, and neglect consideration of his mental equipment and moral proclivities.”

These ideas of physicians as keepers of the nation’s health were also supported by the temperance movement and as a conservative reaction to the massive societal changes that were occurring with industrialization and immigration.

One result of this medical/political battle would lead to both a new understanding of opiates and the “pathologizing” of addiction.

Romayne Gallagher is head of the Division of Residential Care at Providence Health Care in Vancouver and a clinical professor in the Division of Palliative Care at UBC.