by William Santoro, MD, Chief, Section of Addiction Medicine,Reading Hospital, Tower Health System, and Coalition Member
As children we often said, “Sticks and stones can break my bones but names will never hurt me.” How wrong we often were as children.
A word like “addict” is so stigmatizing that it can cause a person to not seek medical attention. The word “addict” is a noun. It labels the person as being the disease rather than having the disease. It allows us to dehumanize the person with the disease.
We all have our own prejudices; how we respond when we discover them says a lot about who we are. I have been telling people for years not to use the word “addict” because of the stigmatizing effects. Then one day the following happened. I was seeing a patient that I
had treated 5 years earlier for addiction. He had been doing well until he simply disappeared. During this return visit I asked him what happened, thinking he would simply say that he relapsed and now had returned to resume his battle with addiction. Instead he told
me that he had been incarcerated for the last 5 years. Because I was so used to asking invasive questions, without thinking, I asked him why he was incarcerated. He told me he had killed someone. At this point I had already started down a slippery slope and I asked him,
“What happened? Was it a drug deal gone bad?”
He replied, “No, nothing like that… it was just a jogger. I killed a jogger while driving.”
Wait a minute, I thought to myself… just a jogger. I could have been that jogger. That jogger was a real person. I didn’t want it to be a real person. I wanted it to be just a drug deal gone bad. You know, then it wouldn’t be like it was a real person because it would have been just an “addict.”
And with that exchange I realized that I, too, had the same prejudices that I ask people to extinguish. Sometimes when we think we are learning we are actually just shuffling our prejudices.
I was giving a conference on the treatment of opioid addiction when I saw a particular physician enter the lecture hall and sit in the back. I found it interesting because I knew this physician and knew that he did not agree with my philosophy of treating this disease.
In fact, he had told me in private conversations that he did not believe this was a disease at all. When it came time for the Q&A nobody raised a hand, except my friend in the back row. I had no other option but to acknowledge him. He proceeded with the following question, “Great talk on heroin addicts, but what do you do with those speed freaks?”
I thought for a moment and decided it was time to confront him. I replied, “Sir, to better answer your question I will need to understand where you are coming from. What is your specialty?”
He looked at me strangely because he knew that I knew his specialty. But he had to answer my question and responded with, “I am an endocrinologist.”
“Oh,” I said, “so you treat those fat, sugar guzzling pigs you call diabetics.” Some immediate shock and a few nervous laughs were heard and I continued, “I mean, what else do you want to call them but liars. The only time a diabetic lies is when he moves his lips. And he is not eating a candy bar. Diabetics will swear on a stack of bibles that they eat nothing but tree bark and grass clippings as their weight goes up and their sugar climbs.” More shock and nervous laughter. I continued, “Now that you are done insulting my patients and I am
done insulting your patients why don’t we get back to doing what we really do – treating people. My patients are not addicts or speed freaks and yours are not fat, sugar guzzling, lying pigs. I treat people addicted to drugs and you treat people with diabetes. The diseases
each of our patients have does not define who they are, but rather what they have.”
Addiction is not new and those suffering from it are not unique.
Like cancer, polio, and any other disease, addiction has a history. It has a history of society accepting it as a disease. It has a history in medicine understanding it as a disease. And it has a history of physicians learning how to treat it as a disease. In order to truly appreciate the unseen destruction of this epidemic we need to see how it has evolved, and in many ways how it has remained the same. The face of addiction’s differences and similarities may startle you.
The History of Opioid Addiction
Opioid addiction first emerged as a serious problem in the United States after the Civil War, when opioids were prescribed widely to alleviate acute and chronic pain. Iatrogenic addiction was by far the most common form of addiction (White 1998). By the late 19th century, two-thirds of those addicted to opioids were middle- and upper-class white women, a fact Brecher and the editors of Consumer Reports (1972, p. 17) attribute to “the widespread medical custom of prescribing opiates for menstrual and menopausal discomfort, and the many proprietary opiates prescribed for ‘female troubles.’” Only one-third of those addicted to opioids at that time became addicted due to nonmedical opioid use mainly among Chinese immigrants
and members of the Caucasian “underground” such as prostitutes, gamblers, and petty criminals.
The chronic nature of opioid addiction soon became evident, however, because many people who entered sanatoriums for a cure relapsed to addictive opioid use after discharge. By the end of the 19th century, doctors became more cautious in prescribing morphine and other opioids, and the prevalence of opioid addiction decreased. Most Americans regarded opioid abuse as socially irresponsible and immoral. It is noteworthy, however, that heroin, introduced in 1898 as a cough suppressant, also began to be misused for its euphoric qualities, gradually attracting new types of users. This development, along with the improvement of the hypodermic needle in 1910-1920, had a profound effect on opioid use and addiction in the 20th century (Courtwright 2001).
The size and composition of the U.S. opioid-addicted population began to change in the early 20th century with the arrival of waves of European immigrants. Most people addicted to opioids in this period were young men in their 20s described as “down-and-outs” of recentimmigrant European descent who were crowded into tenements and ghettos and acquired their addiction during adolescence or early adulthood. They often resorted to illegal means to obtain their opioids, usually from nonmedical sources and specifically for the
The initial treatment response in the early 20th century continued to involve the prescriptive administration of short-acting opioids. By the 1920s, morphine was prescribed or dispensed in numerous municipal treatment programs (Courtwright, et al. 1989). At around the same time addiction to opium, cocaine, and heroin, along with drug-related crime, especially in poor urban communities, started drawing the concerns of political, religious and social leaders. The tolerance and empathy shown toward Civil War veterans and middle-aged women evaporated. Negative attitudes toward and discrimination against new immigrants likely worsened the stigma of addiction. Immigrants and others addicted to drugs were viewed as a threat. Society’s response was to turn from early forms of treatment to law enforcement (Brecher and Editors 1972; Courtwright 2001; Courtwright, et al. 1989).
The shift in the composition of opioid-addicted groups coincided with hardening attitudes toward these groups, leading some researchers to conclude that stigmatization of people with addiction disorders and their substances of abuse reflected, at least in part, class and ethnic biases. A portion of U.S. society appeared to view with disdain and fear the poor White, Asian, African-American, and Hispanic people with addiction disorders who lived in the inner
city ghettos (Courtwright 2001, et al. 1989).
By the mid-1960s, the number of middle-class young White Americans using heroin was on the rise, as was addiction-related crime. This corresponded to the U.S. military involvement in
Vietnam where 25 to 50% of American enlisted men in Vietnam were believed to have used or become addicted to heroin. Serendipitously, the fear that the majority of these Vietnam veterans would return home and continue to abuse heroin did not come to fruition.
In 1962, Dr. Vincent P. Dole, a specialist at The Rockefeller University, became chair of the Narcotics Committee of the Health Research Council of New York City. He received a grant to establish a research unit to investigate the feasibility of opioid maintenance. In preparing for this research, he read “The Drug Addict as a Patient” by Dr. Marie E. Nyswander (Nyswander 1956), a psychiatrist with extensive experience treating patients who were addicted to opioids.
She was convinced that these individuals could be treated within general medical practice. She also believed that many would have to be maintained on opioids because a significant number of people who attempted abstinence without medication relapsed, in spite of
detoxifications, hospitalizations, and psychotherapy (Brecher and editors 1972; Courtwright, et al. 1989). Their research represented a groundbreaking shift in drug addiction treatment.
By the 1980s, an estimated 500,000 Americans used illicit opioids (mainly heroin), mostly poor young minority men and women in the inner cities. Although this number represented a 66% increase over the estimated number of late 19th-century Americans with opioid addiction, the per capita rate was much less than in the late 19th century because the population had more than doubled (Courtwright, et al. 1989). Nevertheless, addiction became not only a
major medical problem but also an explosive social issue (Courtwright 2001; Courtwright, et al. 1989).
In 2002 the passage of the Drug Addiction Treatment Act (DATA-2000), an amendment to the Controlled Substance Act, allowed physicians for the first time in over a century to treat patients with an opioid use disorder in the privacy of their office, using appropriate
opioids. The passage of the Comprehensive Addiction and Recovery Act (CARA) expanded this ability to Certified Registered Nurse Practitioners and Physician Assistants. Providers are mandated to become certified, licensed and follow specific guidelines in their treatment of opioid use disorder.
Currently, our latest statistics show that in 2016 there were over 64,000 deaths due to overdose of drugs. That translates into 180 people dying in the United States every day by overdosing. More than two-thirds of the overdose deaths were caused by opioids. But numbers by themselves do not always hit home. Comparing these numbers may shed some empathy to the human lives lost. I am reminded that 58,000 American soldiers died in the Vietnam War. I am also struck by the fact that there are 180 passenger seats in a typical 737 airplane. We need to ask ourselves if we would tolerate a 737 airplane crashing with no survivors every day. Maybe we need an anti-drug movement similar to the anti-war movement
of the 1960s.
We All have Our Parts To Play
Of course patients need to take responsibility for their actions if these lead to addiction. Pharmaceutical companies need to be held responsible when their products and their actions result in initiating an addiction in patients. In 2007 Purdue Pharmaceutical paid over $600 million in fines for deceptive marketing of OxyContin. Physicians and other medical providers need to take steps to ensure that their prescribing habits do not unduly put patients at risk of addiction. Pennsylvania now has a Prescription Drug Monitoring Program to help providers monitor themselves and their colleagues’ prescribing patterns. Insurance companies need to monitor their approvals and denials of medications that increase or decrease the risk of addiction. And finally, the general public needs to take steps to make certain that when an appropriate, but dangerous, product is prescribed, careful handling and disposing of leftover
medication is done in a way to ensure it does not fall into hands of people who may misuse and become addicted. Programs such as drug take backs allow people to properly, without any questions asked, dispose of unused medications.
The catalyst for addiction came in many forms and for many reasons. But none of those who suffered from the disease willfully volunteered to be subjected to its evils, in the same way you and I would not willfully volunteer to be subjected to cancer or sickle cell anemia. Addiction may not be new but the fact that this is a disease in many ways is. Like it or not, we all now have a role in combating addiction and one tangible way we all can contribute to its suppression is illuminating the stigma of “the addict.”
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