Navigation – Plan du site

AccueilNuméros12Dossier thématiqueFrom one extreme to the other?

Dossier thématique

From one extreme to the other?

The political construction of opioid consensus in the U.S.’s long 20th century
David Herzberg
p. 117-134

Résumé

Cet article porte sur la manière dont l’utilisation des opioïdes aux États-Unis a fait l’objet, au début du xxe siècle puis du xxie siècle, de deux consensus successifs mais opposés, alors même que ces consensus émanaient de groupes dits de « therapeutic reformers » qui ambitionnaient d’asseoir les politiques médicales sur la rationalité scientifique. S’appuyant sur cette notion de « therapeutic reformers » développée par l’historien américain de la médecine Harry Marks dans son ouvrage La médecine des preuves (1999/1997), l’article montre la convergence ponctuelle de ces groupes, sortes de « nébuleuses » réunissant tant des agents publics des administrations étatiques et des instances de régulation des médicaments que des médecins universitaires et praticiens, des pharmaciens ou encore des acteurs industriels. Si Harry Marks avait développé ce concept pour décrire cette alliance d’acteurs à intérêts différents, David Herzberg reprend l’idée d’un projet commun de réforme thérapeutique qui consiste à encadrer l’usage des opioïdes par des arguments qui se veulent « scientifiques », s’appuyant sur des connaissances notamment médicales. L’article montre qu’à presque un siècle d’écart, bien que mus par ce même projet d’objectivité scientifique, les therapeutic reformers parviennent à deux consensus scientifiques opposés quant à l’usage des opioïdes – volonté de restriction des usages même médicaux au début du xxe siècle, libéralisation des consommations au début du xxie siècle –, n’échappant pas aux considérations morales ou économiques entourant la santé.

Therapeutic reformers in the United States built a robust consensus on the use of opioids at the turn of the 20th century; a century later, a slightly different configuration of therapeutic reformers built a new, completely opposite consensus. Both of these achievements were marked by the coalitions required to accomplish them. The first consensus was marred by the influence of moral crusaders determined to maintain social hierarchies of race, class, and gender. The second consensus was corrupted by corporate marketing departments determined to maximize sales. Examining these processes together reveals how therapeutic reformers have remained inextricably embedded in the social and political forces that they hoped to transcend through scientific method. This has had real, and disastrous, consequences for people receiving—or not receiving—opioid treatment for pain.

Haut de page

Texte intégral

  • 1 Cette notion vient de l’auteur américain H. Marks, qui dans son ouvrage The Progress of Experiment (...)

1êTherapeutic reformers1 in the United States built a robust consensus on the use of opioids at the turn of the 20th century; a century later, a slightly different configuration of therapeutic reformers built a new, completely opposite consensus. Both of these achievements were marked by the coalitions required to accomplish them. The first consensus was marred by the influence of moral crusaders determined to maintain social hierarchies of race, class, and gender. The second consensus was corrupted by corporate marketing departments determined to maximize sales. Examining these processes together reveals how therapeutic reformers have remained inextricably embedded in the social and political forces that they hoped to transcend through scientific method. This has had real, and disastrous, consequences for people receiving—or not receiving—opioid treatment for pain.

I. Building the first opioid consensus

2The first consensus promoted a conservative approach to opioids: that they should be used sparingly, as a last resort, only under the close scrutiny of medical and pharmacy professionals, and that they should not be a source of significant profit. This consensus originated with therapeutic reformers in the medical and pharmacy professions, and was formalized into law through political alliance with consumer advocates and moral crusaders. The participation of moral crusaders added a significant and ultimately damaging element of social control: punitive prohibition that prevented socially marginalized communities from accessing opioids and while targeting them for policing and discipline.

A. Medical and pharmacy reformers

  • 2 J. Gabriel, “Restricting the Sale of Deadly Poisons: Pharmacists, Drug Regulation, and Narratives (...)

3Professional medicine and pharmacy in the United States were in disarray at a crucial moment in the history of opioids. The moment was the late 19th century, an era of industrialization, when new technologies and new forms of business made opioids, like many other trade goods, both better and easier to buy. Opioids became better—stronger—thanks to the isolation of morphine from opium and the discovery of the hypodermic syringe. They became easier to buy thanks to the emergence of both a raucous, marketing-driven “patent medicine” industry and more restrained but also efficient “ethical” pharmaceutical companies catering to physicians. Together these two developments posed serious risks for consumers, whose traditional strategies (caveat emptor, or “let the buyer beware”) were insufficient to guide decision-making in such radically new circumstances.2

  • 3 P. Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and t (...)
  • 4 David Courtwright, Dark Paradise: A History of Opiate Addiction in America, enlarged ed. (Cambridg (...)
  • 5 G. B. Wood and F. Bache, The Dispensatory of the United States of America, J.B. Lippincott and Co. (...)
  • 6 J. Gabriel, “Restricting the sale of deadly poisons”; R. Del Rio, “The Drug War Dialectic in Early (...)
  • 7 D. Courtwright, Dark Paradise, ibid., p.26. These numbers include imports of other opioids (e.g., (...)

4At this moment of danger a strong medical and pharmacy consensus on the use of opioids would have been helpful. At a minimum, it might have imposed some degree of restraint on surging markets. But professional medicine and pharmacy in the United States were only beginning their slow climb to authority after decades of relative impotence. With few licensing laws, most physicians received little training, and medical practice was shaped by intense competition in an overcrowded trade.3 Prescribing the patient-pleasing “St. Morphine”, especially in the wake of the Civil War and its many lingering injuries, was difficult to resist.4 The U.S. Dispensatory, the official almanac of medicines, noted in 1858 that opioids were “more frequently prescribed than perhaps any other article of the materia medica”, in part because “there is hardly a complaint which does not occasionally present a complication of symptoms demanding the use of this remedy”.5 Pharmacists, meanwhile, already seeing profits crash thanks to an onslaught of pre-mixed “patent” remedies, were under enormous pressure to sell without asking questions.6 Imports rose from barely over 27,000 pounds of morphine per year in the first half of the century, to over 1.1 million pounds per year in the 1890s.7

  • 8 D. Courtwright, Dark Paradise, ibid., pp. 36–40.
  • 9 H.H. Kane, Drugs that Enslave: The Opium, Morphine, Chloral and Hashisch Habits, Presley Blakiston (...)

5Relatively free prescribing and sales led, predictably, to a sharp increase in a harmful, compulsive type of use that would later be called “addiction”, particularly among what might be called the doctor-visiting classes, i.e., middling or well-off native-born white Americans, especially women.8 “[T]he habitual use of narcotics, once a comparatively rare vice among Christian nations, [has] become alarmingly common”, observed one popular account in 1881.9

  • 10 See H. Marks, The Progress of Experiment: Science and Therapeutic Reform in the United States, 190 (...)
  • 11 P. Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and t (...)
  • 12 N.J. Phenix, “The morphine habit”, Southwestern Medical Record, 1896-1, pp. 206–214. See also S.F. (...)
  • 13 J. Gabriel, “Restricting the sale of ‘deadly poisons’: Pharmacists, drug regulations, and narrativ (...)

6The first people to respond to the crisis were elite, influential leaders in the medical and pharmacy professions that historians describe as “therapeutic reformers”.10 Therapeutic reformers argued that the opioid crisis had been caused, in part, by too-weak medical and pharmacy professions. Most licensing laws had been repealed in the 1820s, meaning that little or no formal education was required before hanging up a physician’s shingle or opening a pharmacy. Moreover, without being able to revoke licenses, therapeutic leaders had few tools to enforce ethical or professional guidelines.11 “A large proportion of habitual narcotism”, wrote one reformist physician in a typical lament, “is due to the thoughtlessness and negligence of medical men”.12 Pharmacy saw a similar crisis. Theirs had traditionally been a healing profession, with druggists making their own remedies from local plants or, in some cases, compounding medicines from bulk substances supplied by a larger pharmaceutical company. As industrialization evolved, however, pre-fabricated compounds — often called “patent medicines”—became an increasing share of the drug market. Druggists risked becoming mere salesmen for standardized commercial goods.13

7This dual crisis—growing rates of opioid addiction, and increasing commercialization—presented an opportunity for professional authorities in both medicine and pharmacy. Seeking to do well by doing good, they proclaimed that only carefully cultivated, robustly enforced professional ethics could protect the public from the inevitable consequences of crass commercial sales of “deadly poisons”.

  • 14 Starr, The Social Transformation of American Medicine; J. Mohr, Licensed to Practice: The Supreme (...)
  • 15 “Lavish” from “Opium Habit’s Power”, New York Times, 1877; “careless” from Kane, Hypodermic Inject (...)
  • 16 Starr, Social Transformation; Mohr, Licensed to Practice; Johnson and Chaudhry, Medical Licensing (...)

8Beginning in the 1870s, therapeutic reformers in medicine were increasingly successful in their campaigns for strong state licensing laws, administered by state medical boards. Such laws enabled reformers to increase educational requirements, and gave medical boards tools to enforce standards of care.14 The opioid crisis provided reformers with the perfect vehicle for their campaign, justifying new licensing laws by railing against physicians who were “too lavish”, “careless”, “weak”, and “almost criminal” in their quick recourse to morphine.15 This type of justification was needed because therapeutic reformers were calling for a legal monopoly on the treatment of illness—a radical restriction of freedom for both sellers and buyers in medical markets.16

  • 17 H.P. Reynolds, “Pharmaceutical morals”, Pharmaceutical Record, June 1, 1887, p. 165., quoted in J.(...)
  • 18 T. L. Corwin, “Has the Pharmacist the Moral Right to Sell Opiates Indiscriminately Even If He Comp (...)
  • 19 D. Blum, The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York, (...)

9As Joseph Gabriel has argued, therapeutic reformers in pharmacy waged a similar campaign. “The shopkeeper naturally inclines to buy and sell anything and everything which will yield an honest profit”, one reformer explained in 1887, but “as pharmacists, having knowledge of the dangerous character of many of our wares … we recognize the need of caution in the sale of deadly poisons and dangerous drugs”.17 They portrayed a stronger profession as a bulwark against “careless” sales, and assured the public of their commitment that druggists had “no moral right to sell indiscriminately, even if he complies with any existing laws”.18 Opioids were among their earliest successes, classified as “poisons” that, beginning in the 1870s, state laws required be properly labeled and sold only by licensed pharmacists who kept records of each transaction.19 By late in the 19th century many (but not all) states required a physician’s prescription for such sales.

10For medicine and pharmacy, then, opioids were both the means by which they achieved professional authority, and an early example of the exercise of that authority. From an intensely competitive boutique trade where every physician or pharmacist was an autonomous agent, medicine and pharmacy became professions disciplined by authoritative guidelines backed by the power to refuse or revoke licenses.

  • 20 The AMA Council on Pharmacy and Chemistry, Useful Drugs, Chicago, IL, Press of the American Medica (...)
  • 21 Overdose warning, see the AMA Council on Pharmacy and Chemistry, Useful Drugs, Chicago, IL, Press (...)

11One of the earliest of these therapeutic guidelines was a conservative approach to the use of opioids. From their perch atop state medical and pharmacy examining boards and medical and specialist societies, therapeutic reformers now urged their colleagues to use opioids as sparingly as possible. The American Medical Association, for example, warned against careless use of morphine in the 1916 edition of Useful Drugs (a handbook for physicians): “morphin should not be used for the relief of pain when any satisfactory relief can be obtained by the use of other drugs”. Moreover, morphine should be used only for “acute pain, not for “chronic conditions associated with pain” except for “such conditions as inoperable cancer, etc., in which the condition is hopeless” and the pain extreme.20 By 1921 the AMA had added a new warning about overdose (“intoxication which may result fatally”) and reminded JAMA readers that care in opioid prescribing was “a matter of professional honor”.21

  • 22 M. Fishbein, “The indispensable uses of narcotics: Introduction”, JAMA 96(11), March 14, 1931, pp. (...)
  • 23 H. C. Wood, Jr., “The indispensable uses of narcotics: The therapeutic uses of narcotic drugs”, JA (...)

12More evidence of the new medical consensus can be found in a series of articles commissioned by JAMA in 1931 titled “The Indispensable Uses of Narcotics”. Nearly a dozen articles covering specialties from surgery to obstetrics were introduced by JAMA editor Morris Fishbein, who advised physicians to “Substitute, whenever possible, non-habit-forming drugs in the place of morphine or other opium alkaloids”, and, when opioids were necessary, to provide as little as possible, for as short a time as possible, providing only enough to last until the next in-person visit.22 The lead article emphasized a similar point with a graphic metaphor: “the physician should use morphine as a miser spends his gold, only when dire necessity requires and in as small amounts as possible”.23 Such views echoed faithfully from specialty organizations and in medical textbooks throughout the 20th century.

B. Consumer advocates and moral crusaders

13By the early 20th century, then, therapeutic reformers had built a clear consensus within the medical and pharmacy professions, and had been rewarded for their troubles with new monopoly powers over the sale of highly desirable products. But as the consensus was not yet inscribed in law, it remained vulnerable. Respectable pharmacists and physicians were heeding reformers’ calls by the turn of the century; but what about others, such as back-alley physicians and pharmacists willing to risk disrepute or the “patent medicine” industry still happily selling its secret-ingredient concoctions? To enforce the consensus on all players in opioid markets would require stronger tools than therapeutic reformers alone could wield.

14For this next step, two new coalition members who shared certain aspects of therapeutic reformers’ concerns were brought on board: consumer advocates and moral crusaders. For consumer advocates, the campaign against opioids was a promising way to do something quite difficult in laissez faire America: build state capacity to regulate markets. Moral crusaders, for their part, were already battling to outlaw “opium dens” and saloons, which they saw as the nexus for multifarious racial threats posed by immigrants from China and southern and eastern Europe. A comprehensive move to restrict sale of addictive drugs to properly constrained practice of medicine and pharmacy fit perfectly with both those other agendas.

  • 24 James Harvey Young, Toadstool Millionaires (Princeton, NJ: Princeton University Press, 2016).
  • 25 S. Hopkins Adams, The Great American Fraud, Articles on the nostrum evil and quackery reprinted fr (...)

15So-called “patent medicine” companies served as a perfect enemy for consumer advocates. As Joseph Gabriel has argued, secret ingredients made sense as a way to protect un-patented drugs from competition, they played havoc with the caveat emptor tradition. How could consumers protect themselves if they could not trust labels and had no idea what they were buying? Moreover, patent medicine companies were notorious for fighting dirty to protect their deceptive practices. For example, they made allies of influential newspaper editors by buying vast quantities of advertising space with a “red clause” in the contract stipulating that the purchase would be canceled if any law restricting patent medicines were to be passed.24 This crooked setup, so characteristic of Gilded Age commerce, drew the ire of “muckraking” investigative journalists like Samuel Hopkins Adams, who wrote an influential series called “The Great American Fraud” that condemned patent medicines as “Subtle Poisons” that “create enslaving appetites”.25

  • 26 Representative Mann, speaking on S. 88, in 40 Cong. Rec. 8892 (1906); see J. H. Young, Pure Food: (...)
  • 27 Harvey C. Wiley speaking to the National Pure Food and Drug Congress in 1898, quoted in O. Anderso (...)
  • 28 An Act for Preventing the Manufacture, Sale, or Transportation of Adulterated or Misbranded or Poi (...)

16Exposé journalism soon connected with professional consumer advocacy through Harvey W. Wiley, head of the U.S. Department of Agriculture’s Bureau of Chemistry. Wiley, already battling against adulterated foods and medicines, eagerly signed on to the campaign against patent medicines. The argument against secret ingredients was uniquely persuasive even in laissez faire America. One representative was met with rousing applause when he told Congress that “we cannot undertake to prevent the man who is an opium fiend from obtaining opium, but we can undertake to prevent the man who never wishes to take opium from taking it without knowing that he is taking it”.26 Wiley himself repeatedly emphasized that reformers’ only goal was that “the innocent consumer may get what he thinks he is buying”.27 The end result was the Food and Drug Act of 1906, the U.S.’s first national consumer protection law. While modest, it still imposed real restraints on the sales of opioids. All drugs had to be labeled honestly, and opioids (and other addictive substances) had to be listed as ingredients.28

  • 29 Lisa McGirr, The War on Alcohol: Prohibition and the Rise of the American State (New York: W. W. N (...)

17The Food and Drug Act might have been enough to satisfy consumer advocates, but not therapeutic reformers. Under the law, sales of any drug were perfectly legal as long as they were properly labeled. For therapeutic reformers, who believed that expert medical knowledge was required in order to use opioids safely, this meant that consumers remained in danger. Addressing this danger required one additional alliance, with the moral crusaders who had already found drugs a useful vehicle for policing what they sometimes referred to as the “dangerous classes” in American cities. By the early 20th century they had already notched victories outlawing smoking opium and, in many states and counties, alcohol too. They were well on their way to achieving national Prohibition of alcohol29. With their political muscle, perhaps sometimes similar could be done with opioids.

18Fortuitously, the U.S. government had already made moral crusaders an instrument of drug policy. Hungry to break into the fabled “China market” but facing better-positioned European empires and a skeptical Chinese government, the U.S. State Department hoped to win favor by championing China’s agenda of international controls on opioid sales—an issue on which the U.S., known internationally for its prudish campaigns against alcohol and sex, had real credibility. To leverage this credibility the U.S. sent evangelical Christian moral crusaders to negotiate with world leaders in a series of international summits starting with the 1909 Shanghai Opium Conference. There was one problem with this strategy, however: the U.S. itself did not have a national drug control law of the sort that its own emissaries were promoting on the world stage.

19The U.S. State Department thus threw its weight behind the domestic push for drug control. Joining now therapeutic reformers, consumer advocates, and moral crusaders, this was more than enough to get over the hump. In fact, the Harrison Anti-Narcotic Act barely made waves when it passed in 1914, despite the protests of at least a few Congressional free marketeers.

20The Harrison Act formalized the conservative consensus originally forged by medical and pharmacy reformers. Opioids could now be sold to the public only through a physician’s prescription filled at a licensed pharmacy. And physicians could only prescribe in the “good faith” practice of medicine, which was defined by the leading lights of the profession—i.e., the conservative approaches detailed above. Transgressors of the Harrison Act would face real criminal penalties, and this included not just ordinary people caught selling, buying, or possessing opioids without a prescription, but also physicians who prescribed for unapproved reasons or in unapproved amounts.

C. Marred from the beginning

21By the 1920s, then, robust consensus had been articulated and implemented in American opioid markets and medical practice. In some respects this achievement looked a lot like what therapeutic reformers aspired to: a rational, evidence-based set of rules to ensure that a medicine was used only in ways proven to maximize benefits and minimize harms. These rules were effective in curbing excessive sales and use of pharmaceutical opioids for the better part of a century—quite an accomplishment in a nation known for its ballyhoo-driven pharmaceutical fads.

22Yet on closer inspection, this seemingly utopian consensus had been marked by the political process that created it. Most devastatingly, common-sense approaches to opioids had been married, forcefully, to a campaign of social control aimed at poor, racialized minorities. The same tools that protected the class of consumers known as “patients” could be used to police and punish the class of consumers increasingly stigmatized as “dope fiends”. It was no coincidence that the “dope fiends” who populated cultural scare campaigns and, increasingly, federal prisons tended to come from immigrant communities, communities of color, and poorer urban communities (all of which overlapped, of course).

23Working alongside a crusade against “dope fiends” also meant that, when the arbiters of the opioid consensus erred, they erred on the side of too much, too heavy-handed control. For one thing, the consensus cruelly abandoned people with addiction, who were legally barred from receiving prescriptions for what would eventually be known as “medication assisted treatment” (i.e., opioids). But the paranoia-inflected presence of moral crusaders also wormed its way into medical guidelines as well. Authorities recommended that opioids be used so sparingly that, by midcentury, even physicians caring for cancer patients literally on death’s door were warned against accidentally fostering addiction.

24Both these damaging flaws festered over time and would eventually be quite useful for a new generation of reformers intent on deconstructing and even reversing the conservative opioid consensus.

II. Building the second consensus

25The end came suddenly after almost a century during which the conservative opioid consensus went nearly unchallenged—surely one of the longest-lived of medical beliefs in the age of continual therapeutic revolutions. Late in the 20th century, a pioneering group of elite medical reformers called for radically rethinking approaches to pain care and, specifically, the use of opioids. Renouncing conservative guidelines that they correctly linked to racist paranoia, they rejected fears that pain patients faced significant risks of addiction if treated with opioids. This was a major, head-on challenge to a century’s worth of conventional wisdom. Coming from influential quarters such as the Memorial Sloan-Kettering Cancer Center, it was not ignored, but neither did it immediately make inroads into traditional practices and beliefs. It was not until the pharmaceutical industry invested in the reformers, and in the larger project of remaking the conservative consensus, that the outlines of a new and ultimately successful version of a reform coalition emerged. There was a new generation of therapeutic reformers, battling not to create but to reorient professional organizations and guidelines. There were latter-day consumer advocates, in this case pain advocacy groups battling against opioid stigma and for patients’ rights to treatment. And there were moral crusaders, still motivated by the longstanding drive to enforce America’s racial hierarchies but now focused on liberating the private sector from regulatory red tape. All were powered by seemingly limitless (and often secret) funding and furious back-channel lobbying by the pharmaceutical industry. Together, in less than a decade, they unwound the conservative consensus and replaced it with its inverse.

26Like the first opioid consensus, the new dispensation had its good points. The emphasis on patient wellbeing and the effort to destigmatize opioid dependence and addiction, for example, were welcome. But the new gospel of opioids was even more deeply corrupted by the strange political bedfellows required to establish it. The combination of heavy pharmaceutical industry influence and almost religiously zealous anti-regulatory crusading meant that the new consensus was ultimately more of a marketing machine than an evidence-based set of therapeutic practices.

A. Remaking medical consensus

  • 30 K. Wailoo, Pain: A Political History, Johns Hopkins University Press, 2014.
  • 31 M. Meldrum, “A brief history of the multidisciplinary management of chronic pain”, in M. Schatman (...)

27The push to reconsider the place of opioids in pain treatment did not come out of nowhere. As Keith Wailoo has argued, the large number of soldiers injured during World War II had prompted a medical pain reform movement at midcentury, led by physicians such as Harvard’s Henry K. Beecher, who urged colleagues to take pain seriously as a medical condition in its own right and to develop treatments specifically for pain.30 Because they saw pain as a complex problem affected by a person’s subjective experiences and attitudes, the approaches they championed were multidisciplinary and included psychiatric, anesthetic, surgical, and pharmacological techniques, as well as political efforts such as defining pain as a form of disability qualifying for Social Security payments. Helping to organize and circulate new research were new professional societies such as the International Association for the Study of Pain (“IASP”), founded by Bonica, Fordyce, and colleagues in 1973. Two years later the IASP began to publish the journal Pain.31

  • 32 R. M. Marks and E. J. Sachar, “Undertreatment of medical inpatients with narcotic analgesics”, Ann (...)
  • 33 R. W. Houde, “Systematic analgesics and related drugs; Narcotic analgesics”, in International Symp (...)
  • 34 Meldrum, “A capsule history”. Note that some pushed for stronger social welfare assistance through (...)
  • 35 M. Angell, “The quality of mercy”, NEJM, 1982-306, pp. 98–99.

28As Marcia Meldrum has shown, one subset of this multifaceted reform movement focused on pain in advanced cancer and other terminal illnesses. At least some of this subset believed that physicians were too reluctant to ease end-of-life suffering with opioids–that the conservative opioid consensus was, in effective, infected by “dope fiend” paranoia and actually harming patients.32 The problem of advanced cancer pain became worse as treatments improved and even terminally ill patients lived longer. So in the 1970s, physician reformers at St. Christopher’s Hospice in London and the Memorial Sloan-Kettering Cancer Center in New York pushed back against the most extreme manifestations of the conservative approach to opioid use that denied palliative care. Studies at both hospitals found that advanced cancer patients did not become easily addicted, and that when used carefully and tailored to the individual, opioids could contribute to increased patient well-being.33 In 1982, the World Health Organization invited many of the most prominent figures in the pain treatment medical community to develop official guidelines for treating cancer pain. The guidelines suggested a “ladder” of treatment, starting with non-opioid painkillers, then moving to weak opioids like codeine, and finally to stronger opioids like morphine.34 Marcia Angell helped raise awareness of the new approaches with a prominent editorial in America’s most prestigious medical journal, the New England Journal of Medicine, warning about cancer pain under-treatment.35

  • 36 K. M. Foley, “Current Issues in the Management of Cancer Pain: Memorial Sloan-Kettering Cancer Cen (...)
  • 37 R.K. Portenoy and K.M. Foley, “Chronic Use of Opioid Analgesics in Non-malignant Pain: Report of 3 (...)

29Among those reformers focused on end-of-life pain care, there was a smaller contingent promoting a far more radical rethinking of opioids for chronic pain more generally. They were not fringe figures; their numbers included such prominent medical elites as Kathleen Foley and Russell Portenoy at Memorial Sloan Kettering Cancer Center. As early as 1981 Foley confronted what she portrayed as unfounded opioid paranoia (or what another reformer called “opiophobia”): “Although fear of addiction limits narcotic use by both physicians and patients, there are no published long-term data to support the thesis that chronic use of narcotic analgesics causes addiction”. Rather, she claimed, citing her own small study, “medical use of narcotics is rarely, if ever, associated with the development of addiction”.36 These ideas received a new and even more prominent airing in 1986 in an article by Foley and her colleague Russell Portenoy which forthrightly rejected what they described as older, unenlightened prejudice against opioids.37

  • 38 D.E. Weissman and J.D. Haddox, “Opioid Pseudoaddiction - an Iatrogenic Syndrome”, Pain 36, March 1 (...)

30Concomitant with the push to reconsider the risks of opioids in pain treatment was a related push against the stigma of addiction in pain patients. One aspect of this was an effort to establish a distinction between opioid “dependence” (a state of physical adaptation in which opioids are required for normal functioning) and opioid “addiction” (compulsive and harmful use of opioids). It was normal, Foley and her colleagues argued, for pain patients to experience the former, and it should not be confused with addiction. A second, more radical version of this reasoning came from J. David Haddox, who defined the concept of “pseudoaddiction” in 1989. When pain patients appeared to exhibit opioid addiction, Haddox argued, for example by hoarding pills, using up their supply before schedule, or even procuring additional opioids illegally, in truth they were probably just being under-treated for pain. Their hunger for more opioids was not addiction but “pseudoaddiction” and should be treated with more opioids.38

31It is impossible to say what might have been the result of these and other provocative ideas had they been subjected to some version of the scientific process, i.e., if they had been dispassionately and deliberately debated among experts based on evidence. Perhaps the conservative opioid consensus might have been revised in beneficial ways. But that did not happen, because opioid manufacturers starting with Purdue Pharma decided to invest heavily in the medical conversation quite early.39 Seemingly limitless funds from industry gave opioid-boosting pain reformers short cuts to prominence and influence. Portenoy, for example, held leadership roles at the American Pain Society, including serving as its President in 1995; the American Pain Foundation; and the American Academy of Pain Medicine. Haddox served as president of AAPM.40

  • 41 J. D. Haddox et al., “The use of opioids for the treatment of chronic pain”, The Clinical Journal (...)

32With opioid evangelists on national speaking tours bankrolled by the pharmaceutical industry and heading major professional organizations, change came swiftly to medical guidelines. In 1997, for example, the AAPM joined with the APS to publish a “consensus statement” on opioids and chronic pain treatment. This statement, written by a committee chaired by Haddox and with Portenoy as its sole consultant, boldly challenged the conservative opioid consensus in a manner that closely followed the industry line. For example, after identifying pain as an increasing medical concern that is “often managed inadequately despite the ready availability of safe and effective treatments”, the statement identified only one of those treatments by name: opioids. It then devoted itself fully to downplaying concerns about what it described as “many commonly held assumptions [that] need modification”. Addiction, for example, should not be feared because “studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low”, and “known addicts can still benefit from the carefully supervised, judicious use of opioids for the treatment of pain”. They dismissed respiratory depression—the cause of fatal overdose—too: “it is now accepted… that respiratory depression induced by opioids tends to be a short-lived phenomenon, generally occurs only in the opioid-naïve patient, and is antagonized by pain”. The statement went on to call for states to provide “guidance” for prescribing physicians, implicitly approving what it described as a “trend” of laws or guidelines that “specifically recognize the use of opioids to treat intractable pain”.41

  • 42 See FSMB, “Model policy for the use of controlled substances for the treatment of pain”, adopted M (...)
  • 43 FSMB, “Model guidelines for the use of controlled substances for the treatment of pain”, adopted M (...)

33With professional societies on board, professional regulatory bodies were not far behind. In 1998, for example, the Federation of State Medical Boards issued new “Model guidelines for the use of controlled substance for the treatment of pain”, developed with the help of the AAPM and APS, among others.42 Closely echoing Joranson’s language, the guidelines argued that “inadequate pain control” was due, in part, to “inadequate understanding of addiction” and “fears of investigation or sanction by federal, state, and local regulatory agencies”. While the new guidelines did mention the existence of “non-pharmacologic modalities”, it focused exclusively on the use of controlled substances, and on reassuring physicians that they should not “fear disciplinary action from the Board or other state regulatory or enforcement agency for prescribing, dispensing, or administering controlled substances, including opioid analgesics”, as long as they had a “legitimate medical purpose”. Indeed, the guidelines specified that “the Board will not take disciplinary action against a physician for failing to adhere strictly to the provisions of these guidelines, if good cause is shown for such deviation”. Evaluation of opioid use would be based not on “quantity and chronicity of prescribing” but on the individual needs of the patient. The guidelines also emphasized that tolerance and physical dependence were “normal physiological consequences of extended opioid therapy for pain and should not be considered addiction”, and that even apparent signs of addiction such as “drug-seeking behavior” could actually be “pseudoaddiction”.43

  • 44 D. Baker, “The Joint Commission’s pain standards: Origins and evolution”, Outlook Terrance, IL: Th (...)
  • 45 D. Baker, “The Joint Commission’s pain standards”; D. Baker, “History of the Joint Commission’s pa (...)

34Another key organization, the Joint Commission on the Accreditation of Healthcare Organizations, collaborated with industry-funded reformers to produce pain standards that would be part of hospital accreditation standards–in other words, required, not recommended, practices.44 The new standards, released in 2001, described pain as the “Fifth Vital Sign” and required that all patients be screened for it by asking them to rate their pain on a numeric scale of 1 to 10.45

  • 46 D. Joranson, A. Gilson, J. Dahl, and J. D. Haddox, “Pain Management, Controlled Substances, and St (...)

35Exhortations and guidelines were not enough for the most radical industry-funded opioid evangelists such as David Joranson and the Pain and Policy Studies Group at the University of Wisconsin-Madison. Joranson and his colleagues argued that “physicians’ fears of being investigated for prescribing opioids” were responsible for America’s “inadequate management of pain”. They urged state medical boards to fix the situation by “adopt[ing] policies that encourage adequate pain management and dispel physicians’ fears of being disciplined”. Doing so, they argued, required an extensive campaign: not just new policies but new enforcement guidelines, new medical education programs, and joint professional-public awareness campaigns. They concluded with a warning: if such efforts did not produce change, “frustration with physicians who do not provide adequate pain management will mount and may lead to policies that penalize inadequate pain management”. Such moves, the authors noted, were already being considered by the prestigious Institute of Medicine and several state boards. “If pain management is to be an expected part of quality medical practice”, they insisted, “then substandard pain management practice must be subject to review and corrective action as in any other area of medical practice”.46 In other words, opioid reformers wanted to use the profession’s disciplinary powers to enforce the new consensus, just as previous generations of therapeutic reformers had done.

B. Consumer advocates and moral crusaders

36Healthcare is a complex and multifaceted social institution, and while physicians are powerful actors in it, they cannot rule by diktat. Two other groups wielded significant influence in how opioids were used: the patients who had to agree to take them, and the federal regulators who had to approve the new medical uses. Both of these groups had been bulwarks of the older consensus; it was not obvious that they would go along easily with the new gospel even if major medical organizations had gotten on board. Fortunately for opioid boosters (and their industry funders), unrelated political developments had created opportunities to convert consumer advocates and moral crusaders to the cause.

  • 47 L. Richert, A Prescription for Scandal: Conservatism, Consumer Choice, and the Food and Drug Admin (...)

37Consumer advocacy in medicine had developed new elements by the end of the HIV/AIDS crisis. For most of the 20th century, consumer advocates had, if anything, seen the FDA as too weak in overseeing industry and had clamored for more stringent controls. Starting with advocates of “alternative” medicine (such as the supposed anti-cancer drug laetrile) in the 1970s, however, new popular consumer constituencies emerged making the opposite argument—that a bureaucratic, conservative FDA was denying life-saving drugs to people who wanted them. Such criticisms became more urgent during the HIV/AIDS crisis, when activists quite reasonably believed they saw a connection between the FDA’s slowness on approving treatments to entrenched homophobia in the federal government.47 For the first time in the 20th century, consumers were organized to demand less regulation of the pharmaceutical industry rather than more.

  • 48 Homeland Security and Government Affairs Committee (HSGAC), 2018a. Fueling an epidemic–Report Two: (...)
  • 49 C. Ornstein and T. Weber, “The champion of painkillers”, ProPublica, December 23, 2011, https://ww (...)

38This new variant of medical consumer activism provided an ideal opening for opioid boosters, who quickly organized so-called “astroturf” patient groups to advocate for easier opioid access. “Astroturf”, or the plastic grass used for indoor sporting events, indicated that the groups did not spring up from real “grassroots” activism but were rather created, and funded, by the pharmaceutical industry. To promote expanded use of opioids for chronic pain, opioid manufacturers developed or invested in a wide range of patient advocacy groups, for example giving $9 million to fourteen different groups such as the American Pain Foundation from 2012 to 2017.48 The APF issued patient guides that praised opioids while criticizing other forms of pain control (for example, pointing to side effects of aspirin and ibuprofen). These guides also instructed patients in key aspects of the new opioid consensus such as “pseudoaddiction”. Meanwhile, the APF also galvanized patient activism through such forms as letter-writing campaigns to complain about unfavorable media representations of opioids and opioid users, and working to protect patient access to opioids by intervening in court cases to defend opioids and opioid prescribers.49 Similar advocacy groups armed pain patients with information about the new opioid consensus and, in some cases, provided advice and strategies for demanding opioid treatment from reluctant physicians.

  • 50 See Richert and Carpenter.
  • 51 See, e.g., C. Esch, “How one sentence helped set off the opioid crisis”, NPR’s Marketplace, Decemb (...)
  • 52 See, e.g., P. Beall, “Rudy Giuliani, the DEA and the free flow of oxy”, Palm Beach Post, https://h (...)

39The new pro-opioid consumer advocacy had a partner with a new variant of what could be considered moral crusaders. In this case, the crusaders worked on behalf of what critics call neoliberalism, an economic philosophy holding that all social resources should be allocated by lightly regulated private-sector markets. It was an article of faith among neoliberals that government “interventions” such as regulations were a priori unnecessary and harmful. Neoliberal critics had been raging against the FDA since the 1960s, for example, claiming that the agency was essentially murdering Americans by preventing them from accessing life-saving new miracle drugs developed by industry. After the election of Ronald Reagan in 1980, these neoliberal critics turned to governing. During Reagan’s presidency and after—even during the administrations of Democrats Bill Clinton and Barack Obama—the neoliberal attitude towards federal drug regulations remained strong. The FDA, for example, was encouraged to ease up on its traditional skeptical, adversarial stance towards industry, and instead strive to be a partner that could help industry speedily get its drugs through the approval process.50 Such attitudes appear to have smoothed the path to approval of Purdue Pharma’s OxyContin to treat chronic pain.51 The DEA, for its part, was directed to reduce policing of the pharmaceutical industry (where it had ramped up operations in the regulatory heyday of the 1970s) and turn its attention and resources to chasing “street” drug sales and use instead.52

  • 53 Craig Reinarman and Harry Levine, eds., Crack in America: Demon Drugs and Social Justice (Berkeley (...)

40Neoliberals can be categorized as “moral crusaders” in the context of drug policy for a specific set of reasons. First and most directly, their push to cut back government regulations was, in the U.S., paired with a push to ramp up and expand government capacity to reinforce social hierarchies by regulating “vice”, similar to what moral crusaders had done in the past with, for example, the Prohibition of alcohol. In this case the same neoliberals pushing for reduced DEA oversight of the pharmaceutical industry were successfully advocating for a renewed “drug war” that, beginning with the “crack” cocaine crisis of the 1980s, grew into a substantial contributor to mass incarceration—a process so racially unequal that some observers have called it a “new Jim Crow”.53 This was in keeping with neoliberals’ broader campaign to reduce or eliminate government programs such as “welfare” and affirmative action that were designed to extend full social citizenship to people of color and other marginalized groups.

41Once again, then, therapeutic reformers seeking to build a consensus around opioids relied on the support of look consumer advocates and moral crusaders to build popular support and to institutionalize new attitudes in government policy.

C. A disastrous consensus

42However worthy its first origins, the new pro-opioid consensus led to a public health catastrophe. Marketing-driven sales spikes flooded American communities with opioid pills that carried a stamp of approval from medical authorities. Consumers—both patients and patients’ families and friends—swallowed them with less caution, leading to widespread increases in addiction and related harms.

43Ironically, the push against opioid paranoia and stigma did little to ease the social control dimension of the first opioid consensus. The push to rethink opioids was exclusively for the relatively privileged type of consumers known as “patients”. Only pain patients’ addiction became “dependence” or “pseudoaddiction”; non-medical consumers remained troublesome “abusers”. In 2007, when opioid manufacturers faced their first round of blame for what was already clearly a public health crisis, industry-funded opioid boosters doubled down on this distinction to preserve the new consensus. They blamed “abusers” for the addiction crisis, and encouraged lawmakers to exclude and punish them rather than reining in out-of-control prescription markets. New policies to cut off people with addiction from pain pills transformed a crisis of addiction into a crisis of overdose, as they turned to “street” drugs of unknown provenance increasingly adulterated with fentanyl.

Conclusion

44Medical consensus regarding opioids in the U.S. has been achieved twice in the long 20th century. Both times, therapeutic reformers achieved success through political coalition with consumer advocates and moral crusaders, and both times, that coalition profoundly influenced the nature and consequences of the new consensus. In the first consensus, borrowing the political muscle of moral crusaders meant incorporating their social control agenda into the very heart of American ideas about opioid addiction, ensuring that consumer protections would at the same time be a regime of punitive prohibition. In the second consensus, therapeutic reform became little more than a vehicle for pharmaceutical industry influence, again remaking ideas of addiction and gutting consumer protections—without ending the racist social control elements.

Haut de page

Notes

1 Cette notion vient de l’auteur américain H. Marks, qui dans son ouvrage The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900–1990 vise par là un groupe disparate de pharmacologues, médecins, statisticiens, hommes politiques, etc. qui, tenants d’une médecine moderne plus « scientifique », ont aux États-Unis, au début du xxe siècle, promu la pratique systématique des essais cliniques contrôlés. H. Marks montre que l’histoire des médicaments modernes se confond avec celle de la réforme thérapeutique et comment elle a transformé le marché de la santé. V. H. MarksThe Progress of Experiment: Science and Therapeutic Reform in the United States, 1900-1990, Cambridge History of Medicine, New York, Cambridge University Press, 1997. L’ouvrage a été traduit en français sous l’intitulé La médecine des preuves. Histoire et anthropologie des essais cliniques (1900-1990), Synthélabo-Les Empêcheurs de penser en rond, 1999.

2 J. Gabriel, “Restricting the Sale of Deadly Poisons: Pharmacists, Drug Regulation, and Narratives of Suffering in the Gilded Age”, Journal of the Gilded Age and Progressive Era 3, 2010, pp. 313–336.; N. Tomes, Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers, Chapel Hill, University of North Carolina Press, 2016.

3 P. Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry, New York, Basic, 2017 [1982]); J. Mohr, Licensed to Practice: The Supreme Court Defines the American Medical Profession, Baltimore, Johns Hopkins University Press, 2013.; D. Johnson and H. Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards, Lanham, MD, Lexington, 2012.; R. Horowitz, In the Public Interest: Medical Licensing and the Disciplinary Process, New Brunswick, NJ, Rutgers University Press, 2013.

4 David Courtwright, Dark Paradise: A History of Opiate Addiction in America, enlarged ed. (Cambridge, MA: Harvard University Press, 2001; first published 1982).

5 G. B. Wood and F. Bache, The Dispensatory of the United States of America, J.B. Lippincott and Co., 1858, pp. 568–569, available at https://babel.hathitrust.org/cgi/pt?id=hvd.hc18xt&view=1up&seq=7 (last accessed August 7, 2020); Samuel Potter agreed in the 1894 edition of his textbook Handbook of Materia Medica, Pharmacy and Therapeutics (P. Blakiston, Son & Co., 1894), available at: https://babel.hathitrust.org/cgi/pt?id=loc.ark:/13960/t9m343m4n&view=1up&seq=11, 318 (last accessed August 7, 2020): “Probably no drug in the Materia Medica is so useful as Opium, or has so wide a range of application”. See also D. Courtwright, Dark Paradise: A History of Opiate Addiction in America, Harvard University Press, 2001, p. 48.

6 J. Gabriel, “Restricting the sale of deadly poisons”; R. Del Rio, “The Drug War Dialectic in Early Twentieth-Century Chicago,” Social History of Alcohol and Drugs 34(2), Fall 2020, 297-319; for further analysis see Del Rio’s excellent dissertation, Drug Trades and Drug Wars: The Mass Transformation of Retail Pharmacy and the Development of a Modern Illicit Narcotics Market in Chicago, 1870-1926 (University of Chicago, August 2018).

7 D. Courtwright, Dark Paradise, ibid., p.26. These numbers include imports of other opioids (e.g., opium, etc.), that Courtwright converted into “morphine equivalent” amounts.

8 D. Courtwright, Dark Paradise, ibid., pp. 36–40.

9 H.H. Kane, Drugs that Enslave: The Opium, Morphine, Chloral and Hashisch Habits, Presley Blakiston, 1881. Available at: https://babel.hathitrust.org/cgi/pt?id=hvd.32044107280216&view=1up&seq=17 (last accessed August 7, 2020).

10 See H. Marks, The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900-1990, Cambridge University Press, 2000.; J. Gabriel, Medical Monopoly: Intellectual Property Rights and the Origins of the Modern Pharmaceutical Industry, University of Chicago Press, 2014.

11 P. Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry, Basic Books, 2017 [1983].

12 N.J. Phenix, “The morphine habit”, Southwestern Medical Record, 1896-1, pp. 206–214. See also S.F. McFarland, “Opium Inebriety and the Hypodermic Syringe”, Transactions of the Medical Society of the State of New York, 1877, pp. 289–293.; Nickeson, “Relation of physicians to the narcotic habit”, Journal of Medicine and Science, 1900, pp. 50–51.; J.A. Witherspoon, “A protest against some of the evils in the profession of medicine”, JAMA 34, 1900, pp. 1589–1592; W.S. Watson, “On the evil of opium eating”, JAMA 14 (19), 1890, pp. 671–674.

13 J. Gabriel, “Restricting the sale of ‘deadly poisons’: Pharmacists, drug regulations, and narratives of suffering in the Gilded Age”, Journal of the Gilded Age & Progressive Era 9(3), July 2010, pp. 317–318.

14 Starr, The Social Transformation of American Medicine; J. Mohr, Licensed to Practice: The Supreme Court Defines the American Medical Profession, Baltimore, Johns Hopkins University Press, 2013.; D. Johnson and H. Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards, Lanham, MD, Lexington, 2012.

15 “Lavish” from “Opium Habit’s Power”, New York Times, 1877; “careless” from Kane, Hypodermic Injection, 268, pp. 306–307, and “Opium Habit”, Catholic World, 1881.; “weak” from Kane, Drugs That Enslave, 18; “almost criminal” from “Women Victims of Morphine”, New York Times, October 25, 1895. See also, e.g., N. J. Phenix, “The Morphine Habit”, Southwestern Medical Record, 1896, pp. 206–214; Courtwright, Dark Paradise; David Musto, American Disease: Origins of Narcotics Control, rev. ed. (1973; repr., New York: Oxford University Press, 1999).

16 Starr, Social Transformation; Mohr, Licensed to Practice; Johnson and Chaudhry, Medical Licensing and Discipline in America.

17 H.P. Reynolds, “Pharmaceutical morals”, Pharmaceutical Record, June 1, 1887, p. 165., quoted in J. Gabriel, “Restricting the sale of ‘deadly poisons’: Pharmacists, drug regulations, and narratives of suffering in the Gilded Age”, Journal of the Gilded Age & Progressive Era 9(3), July 2010, pp. 313–336.

18 T. L. Corwin, “Has the Pharmacist the Moral Right to Sell Opiates Indiscriminately Even If He Complies with any Existing Laws as to Its Registration ?”, Pharmaceutical Record, July 1885, p. 204. cited in Gabriel, “Deadly Poisons”, p. 330.

19 D. Blum, The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York, Penguin, 2011, pp. 1–3, cited in M. Jones and D. Benrubi, “Poison politics: A Contentious History of Consumer Protection Against Dangerous Household Chemicals in the United States”, American Journal of Public Health 103(5), May 2013, pp. 801–812.; see also G. Sonnedecker and E. Kremers, Kremers and Urdang’s History of Pharmacy, American Institute for the History of Pharmacy, 1986, p. 216.

20 The AMA Council on Pharmacy and Chemistry, Useful Drugs, Chicago, IL, Press of the American Medical Association, 1916, pp. 97–98. Available at: https://babel.hathitrust.org/cgi/pt?id=hvd.hc33dm&view=1up&seq=5 (last accessed August 7, 2020). The U.S. Dispensatory had come around as well, cautioning in 1916 that “the opium-habit is an exceedingly common condition, arising from abuse of the drug” (1185); H. Hare, C. Caspari, H. Rusby, U.S. Dispensatory (Lea & Febiger, 1916). Available at: https://babel.hathitrust.org/cgi/pt?id=osu.32435013830088&view=1up&seq=7 (last accessed August 7, 2020).

21 Overdose warning, see the AMA Council on Pharmacy and Chemistry, Useful Drugs, Chicago, IL, Press of the American Medical Association, 1921, p. 103. Available at: https://babel.hathitrust.org/cgi/pt?id=uc1.b4484913&view=1up&seq=11 (last accessed August 7, 2020); “professional honor” quote from “New narcotic drug instructions”, JAMA 27(18), 1921, p. 1427. See also “New regulations for narcotic drugs”, JAMA 27(18), 1921, p. 1431.

22 M. Fishbein, “The indispensable uses of narcotics: Introduction”, JAMA 96(11), March 14, 1931, pp. 856–857.

23 H. C. Wood, Jr., “The indispensable uses of narcotics: The therapeutic uses of narcotic drugs”, JAMA 96(14), April, 1931, p. 1142. See also, e.g., F. Tice, “The indispensable uses of narcotics: In the practice of medicine”, JAMA 96(12), March 21, 1931, pp. 944–946; R. Hatcher, “The indispensable uses of narcotics: In the treatment of coughing”, JAMA 96(17), April 25, 1931, pp. 1383–1386; R. Hatcher, “The indispensable uses of narcotics: In the treatment of diseases of the gastro-intestinal tract”, JAMA 96(18), May 1931, pp. 1475–1477.

24 James Harvey Young, Toadstool Millionaires (Princeton, NJ: Princeton University Press, 2016).

25 S. Hopkins Adams, The Great American Fraud, Articles on the nostrum evil and quackery reprinted from Collier’s, American Medical Association, 1906, pp. 32–39. Available at: https://www.google.com/books/edition/The_Great_American_Fraud/Gi5L8N0RX0QC?hl=en&gbpv=1&printsec=frontcover (last accessed August 7, 2020). See also Young, Toadstool Millionaires, pp. 17–18.

26 Representative Mann, speaking on S. 88, in 40 Cong. Rec. 8892 (1906); see J. H. Young, Pure Food: Securing the Federal Food and Drugs Act of 1906, Princeton, NJ, Princeton University Press, 1989, p. 257.

27 Harvey C. Wiley speaking to the National Pure Food and Drug Congress in 1898, quoted in O. Anderson, The Health of a Nation: Harvey W. Wiley and the Fight for Pure Food, Chicago, University of Chicago Press, 1958, pp. 124–125.

28 An Act for Preventing the Manufacture, Sale, or Transportation of Adulterated or Misbranded or Poisonous or Deleterious Foods, Drugs, Medicines, and Liquors . . . , Pub. L. No. 59-384, 34 Stat. 768 (1906).

29 Lisa McGirr, The War on Alcohol: Prohibition and the Rise of the American State (New York: W. W. Norton, 2016)

30 K. Wailoo, Pain: A Political History, Johns Hopkins University Press, 2014.

31 M. Meldrum, “A brief history of the multidisciplinary management of chronic pain”, in M. Schatman and A. Campbell (Eds.), Chronic Pain Management: Guidelines for Multidisciplinary Program Development, CRC Press, Taylor & Francis, 2007.; Wailoo, Pain.

32 R. M. Marks and E. J. Sachar, “Undertreatment of medical inpatients with narcotic analgesics”, Annals of Internal Medicine, 1973-78, pp. 173–181.; J. P. Morgan and D. L. Pleet, “Opiophobia in the United States: The undertreatment of severe pain”, in J. P. Morgan and D. V. Kagan (Eds.), Society and Medication: Conflicting Signals for Prescribers and Patients, Lexington, MA, Lexington Books, 1983, pp. 313–326, cited in M. Meldrum, “The prescription as stigma”, Greene and Watkins (Eds.), Prescribed, p. 189. See also J. Bourke, The Story of Pain: From Prayer to Painkillers, Oxford University Press, 2014, pp. 291–295.

33 R. W. Houde, “Systematic analgesics and related drugs; Narcotic analgesics”, in International Symposium on Pain of Advanced Cancer, ed. J. J. Bonica and V. Ventafridda, Advances in Pain Research and Therapy, Vol 2, New York, Raven Press, 1979, pp. 263–273. (Sloan Kettering study); R. G. Twycross, “Choice of strong analgesic in terminal cancer: Diamorphine or morphine ?”, Pain 3, 1977, pp. 93–104; and R. G. Twycross, “Overview of analgesia”, in Bonica and Ventafridda, International Symposium on Pain, pp. 617–633 (St. Christopher study), all cited in Meldrum, “The prescription as stigma”, pp. 190–191.

34 Meldrum, “A capsule history”. Note that some pushed for stronger social welfare assistance through the Social Security Act’s disability program; see Wailoo, Pain: A Political History.

35 M. Angell, “The quality of mercy”, NEJM, 1982-306, pp. 98–99.

36 K. M. Foley, “Current Issues in the Management of Cancer Pain: Memorial Sloan-Kettering Cancer Center”, New Approaches, p. 170. and p. 178.

37 R.K. Portenoy and K.M. Foley, “Chronic Use of Opioid Analgesics in Non-malignant Pain: Report of 38 Cases”, Pain 25, 1986, pp. 171–186.

38 D.E. Weissman and J.D. Haddox, “Opioid Pseudoaddiction - an Iatrogenic Syndrome”, Pain 36, March 1989, pp. 363–366.

39 See, e.g., https://www.drugwatch.com/featured/opioid-crisis-big-pharma/; T. Weber and C. Ornstein, “Two Leaders in Pain Treatment Have Long Ties to Drug Industry”, ProPublica, December 23, 2011, https://www.propublica.org/article/two-leaders-in-pain-treatment-have-long-ties-to-drug-industry

40 See Portenoy’s 2001 self-description to the U.S. Senate, https://www.help.senate.gov/imo/media/doc/Portenoy.pdf (last accessed August 7, 2020); for Haddox’s AAPM Presidency, see, e.g., https://www.ncbi.nlm.nih.gov/pubmed/9874004 (last accessed August 7, 2020).

41 J. D. Haddox et al., “The use of opioids for the treatment of chronic pain”, The Clinical Journal of Pain 13 (1), March 1997, pp. 6–8.

42 See FSMB, “Model policy for the use of controlled substances for the treatment of pain”, adopted May 2004, “Introduction”, https://dprfiles.delaware.gov/medicalpractice/Model_Policy_Treatment_Pain.pdf (last accessed August 7, 2020).

43 FSMB, “Model guidelines for the use of controlled substances for the treatment of pain”, adopted May 2, 1998, https://web.archive.org/web/20021203180700fw_/http://www.fsmb.org/Policy Documents and White Papers/model_pain_guidelines.htm, last accessed August 8, 2020.

44 D. Baker, “The Joint Commission’s pain standards: Origins and evolution”, Outlook Terrance, IL: The Joint Commission, 2017.

45 D. Baker, “The Joint Commission’s pain standards”; D. Baker, “History of the Joint Commission’s pain standards: Lessons for today’s prescription opioid epidemic”, JAMA 317(11), March 21, 2017, pp. 1117–1118.

46 D. Joranson, A. Gilson, J. Dahl, and J. D. Haddox, “Pain Management, Controlled Substances, and State Medical Board Policy: A Decade of Change”, Journal of Pain and Symptom Management, n°2, 2002-23, pp. 138–147.

47 L. Richert, A Prescription for Scandal: Conservatism, Consumer Choice, and the Food and Drug Administration during the Reagan Era, Lanham, MD, Lexington, 2014; D. Carpenter, Reputation and Power: Organizational Image and Pharmaceutical Regulation at the FDA, Princeton, NJ, Princeton University Press, 2010; A. S. Bix, “Diseases chasing money and power: Breast cancer and AIDS activism challenging authority”, Journal of Policy History, 9(1), January 1997, pp. 5–32.

48 Homeland Security and Government Affairs Committee (HSGAC), 2018a. Fueling an epidemic–Report Two: Exposing financial ties between opioid manufacturers and third party advocacy groups. Washington, D.C.: U.S. Senate. https://www.hsdl.org/?view&did=808171. For APF see also C. Ornstein and T. Weber, “American Pain Foundation Shuts Down as Senators Launch Investigation of Prescription Narcotics”, ProPublica, May 8, 2012, https://www.propublica.org/article/senate-panel-investigates-drug-company-ties-to-pain-groups.

49 C. Ornstein and T. Weber, “The champion of painkillers”, ProPublica, December 23, 2011, https://www.propublica.org/article/the-champion-of-painkillers. For APF publication see American Pain Foundation, Treatment Option s: A Guide for People Living with Pain, https://www.documentcloud.org/documents/277605-apf-treatmentoptions.

50 See Richert and Carpenter.

51 See, e.g., C. Esch, “How one sentence helped set off the opioid crisis”, NPR’s Marketplace, December 13, 2017, https://www.marketplace.org/2017/12/13/opioid/.

52 See, e.g., P. Beall, “Rudy Giuliani, the DEA and the free flow of oxy”, Palm Beach Post, https://heroin.palmbeachpost.com/rudy-giuliani-dea-free-flow-of-oxy/; for later, successful efforts to muzzle the DEA, see, e.g., L. Bernstein and S. Higham, “The DEA slowed enforcement while the opioid epidemic grew out of control”, Washington Post, October 22, 2016, https://www.washingtonpost.com/investigations/the-dea-slowed-enforcement-while-the-opioid-epidemic-grew-out-of-control/2016/10/22/aea2bf8e-7f71-11e6-8d13-d7c704ef9fd9_story.html?utm_term=.cfdcdfd78502; L. Bernstein and S. Higham, “‘We feel like our system was hijacked’: DEA agents say a huge opioid case ended in a whimper”, Washington Post, December 17, 2017, https://www.washingtonpost.com/investigations/mckesson-dea-opioids-fine/2017/12/14/ab50ad0e-db5b-11e7-b1a8-62589434a581_story.html?hpid=hp_hp-banner-low_mckesson-603am-hed%3Ahomepage%2Fstory&utm_term=.bc9cfbcd3f59; B. Whitaker, “DEA attorneys went easy on McKesson, the country’s largest drug distributor”, 60 Minutes/Washington Post, December 17, 2017, https://www.cbsnews.com/news/whistleblowers-dea-attorneys-went-easy-on-mckesson-the-countrys-largest-drug-distributor/; S. Higham and L. Bernstein, “The drug industry’s triumph over the DEA”, Washington Post, October 15, 2017, https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/.

53 Craig Reinarman and Harry Levine, eds., Crack in America: Demon Drugs and Social Justice (Berkeley: University of California Press, 1997); Michelle Alexander, The New Jim Crow: Mass Incarceration in the Age of Colorblindness (New York: New Press, 2012); Julilly Kohler-Hausmann, Getting Tough: Welfare and Imprisonment in 1970s America (Princeton, NJ: Princeton University Press, 2017).

Haut de page

Pour citer cet article

Référence papier

David Herzberg, « From one extreme to the other? »Cahiers Droit, Sciences & Technologies, 12 | 2021, 117-134.

Référence électronique

David Herzberg, « From one extreme to the other? »Cahiers Droit, Sciences & Technologies [En ligne], 12 | 2021, mis en ligne le 07 mai 2021, consulté le 13 juillet 2024. URL : http://journals.openedition.org/cdst/3493 ; DOI : https://doi.org/10.4000/cdst.3493

Haut de page

Auteur

David Herzberg

Associate professor, University at Buffalo, History Department

Haut de page

Droits d’auteur

CC-BY-4.0

Le texte seul est utilisable sous licence CC BY 4.0. Les autres éléments (illustrations, fichiers annexes importés) sont « Tous droits réservés », sauf mention contraire.

Haut de page
Rechercher dans OpenEdition Search

Vous allez être redirigé vers OpenEdition Search