Where do opiates and heroin come from?
What’s the difference between the prescription painkillers?
How did opiate addiction get so bad?
The opiate epidemic is all around us. We hear about the deaths and the dangers. Most of us know a bit about it, but we may not know enough details to help our addicted clients. This is the first part of a mini-series about opiates and heroin. The goal is to help you get a clear picture of this issue, how it impacts people and what treatment looks like.
**These links represent what I read and where I got information. Some information is conflicting, but included to show the full spectrum of information considered.
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You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance podcast. This is episode 23. For the next few weeks we’re going to be talking about opiates, opioids, and heroin. Most of us have seen information on the internet or on the news about opiates and the epidemic.
We know that people are abusing prescription meds, they’re using heroin and that overdose is an ever-present threat. There’s more information though, that I believe that we need to know as therapists in order to better help our clients.
Heroin: A history
We’re going to start at the beginning. Heroin, morphine and other opiates trace their origin to a single plant: the poppy plant. Cultivation of this plant dates back to the earliest years of human civilization. Opium use was well-known in Mesopotamia, Sumeria, spreading to the ancient Greeks, Persians, and Egyptians.
Homer refers to the healing properties of opium in The Odyssey. Ancient societies used opium to aid with sleep, relieve pain, and it suggested even to calm crying children. There’s some evidence to suggest it was used during surgery. They may have also used it recreationally, but we don’t have evidence of that.
In the 1700’s, the British conquered the major poppy growing region of India. Rather than get rid of the production, began to smuggle opium from India to China through the East India Trading Company. Following were two Opium Wars, which was in response to China trying to get a handle on the opium epidemic and get rid of opium use in their country.
A German scientist, first isolated morphine from opium in 1803. Morphine is the active narcotic agent in opium and in its pure form is 10 times stronger than opium. This was widely used as a painkiller during the US Civil War and an estimated 400,000 soldiers became addicted.
By the second half of the 19th century scientists began looking for a less addictive form of morphine and were able to refine heroin from the morphine base in 1874. Morphine is still the precursor to all opiates, including codeine, fentanyl, methadone, hydrocodone otherwise known as Vicodin, hydromorphone otherwise known as Dilaudid, Meperidine otherwise known Demerol and oxycodone, otherwise known as Percocet or Oxycontin.
In the 1890s, the pharmaceutical company, Bayer marketed heroin as a morphine substitute and as a cough suppressant. In 1905, the U S Congress banned opium. At the time heroin was being used to treat morphine addiction. In 1906, the U S Congress passed the Pure Food and Drug Act requiring content labeling on patented medicines by pharmaceutical companies. The availability of opiates would decrease significantly because of this act, at least through prescription means.
I think it’s important to note when we’re talking about history the opium was being sold in China and perpetuated by outside governments like the French and the British. The Chinese government was fighting against the opium epidemic in their own country. But the French and the British and other governments really wanted these ports to stay open so that they could continue pushing opium through it. It brought them a lot of money, as drugs usually do.
Opium use began being associated with Chinese people and it sparked a lot of prejudice and racism against Chinese people, portraying them all as opiate addicts. In 1910, after 150 years of fighting the opium trade, the Chinese were finally successful in convincing the British to dismantle the India-China opium trade. In 1923 the US Treasury Department’s Narcotic Division banned all legal narcotic sales. So not being able to buy narcotics products in a legal way, a thriving black market opened up in New York around 1925.
Through the US’s involvement in different conflicts in Asia, an increase in the availability of heroin and opium is seen in the US. There has been a fight against opium, heroin, morphine for hundreds of years. The US even participated in spraying fields in Mexico with Agent Orange in an effort to crush production of the narcotics.
Heroin is being discussed publicly all over with the news that Janis Joplin died from a heroin overdose in 1970. In 1982 comedian John Belushi would die from reportedly using a “speedball” which is heroin and cocaine. In 1994, Kurt Cobain is said to have died from a heroin induced suicide.
In the mid nineties heroin seems, to me at least, to be a street drug found in inner cities and with “serious” drug addicts. It wasn’t until a little bit later that it started making its way to the suburbs where I lived. Around the same time we start seeing the use of prescription pills, skyrocket.
Heroin: Opiates in all its forms
Heroin’s scientific name is diacetylmorphine. There are three types of opioid drugs: opiates, synthetic opioids and semi-synthetic opioids. Semi-synthetic opioids are created in labs from naturally occurring opiates. Synthetic opioids are created entirely in a lab without the naturally occurring opiate base. Morphine and codeine are two of the most commonly known natural opiates.
Semi-synthetic opioids are things like heroin, hydrocodone (otherwise known as Lortab or Vicodin), hydromorphone (otherwise known as Dilaudid), and oxycodone (otherwise known as Percocet or Oxycontin). The semi-synthetic drugs are created to mimic the effects of natural opiates.
Fully synthetic opioids are entirely manmade and have a different chemical structure from opiates, but produce opiate like effects such as methadone, Demerol, Ultram or Tramadol, fentanyl, and levophorphenol.
I know this is a lot of different medication names and some of them, you probably recognize. So I want to tell you the basic structure of potency from lowest to highest. So on the low end, we have something like Tramadol or Ultram. Tramadol wasn’t included as a scheduled substance until within the last five to 10 years. It’s considered the weakest opioid, but it can definitely still lead to addiction.
Next up, Demerol, this was the first synthetic opiate to reach the market. Next, codeine it’s typically used in a form of what we call Tylenol-3 and given for pain while you’re at the hospital or dental procedures, or it’s often used in cough syrup, both with prescriptions. Next up, hydrocodone. So Lortab or Vicodin. After that morphine.
Next in line oxycodone, examples are Oxycontin and Percocet. Next Methadone. Followed by oxymorphone also called Opana. Then hydromorphone also known as Dilaudid. Then heroin, fentanyl and carfentanil.
So let’s talk about how this over prescribing happened. Doctors find themselves at the heart of this controversy. While the prescriptions did come from doctors, the majority of doctors were well-meaning and trying to treat their patients’ pain. I’ve heard doctors speak about this and they have regrets and anguish over what has happened.
Accounts online to accounts I’ve heard personally, this is the story. Doctors get into the business of doctoring, for the most part, to help people. Yes, of course there’s money to be made, but going through medical school and residency and everything else is not for the faint of heart.
In the mid to late nineties information was coming out that doctors were under prescribing medications for pain and it was brought up as a patient rights issue. Patients have a right to have their pain managed. As a result, some doctors were being sued for their lack of willingness to treat pain. Doctors want to help people. When they have a patient in their office that’s in pain and they have a medication that will help, they prescribe it.
The sheer amount of information that doctors have to keep in their head and know on a given basis is staggering. If you think about the number of different medications, the number of different ailments, illnesses and the obscure ones that people get, but it’s rare. They have to know all of these things. They rely on new information and studies coming to them to be accurate.
One physician described himself and others as innocent bystanders. He admits that “We over prescribe opioids. We overprescribe antibiotics. We don’t want our patients to experience pain. It’s typical for physicians to prescribe 30 or 60 pills when five or 10 would have done it.” They know that prescribing a small number is going to result in a call from the pharmacy or from the patient.
What we have to know is that at the time physicians were being fed, in some cases, misinformation and in others outright lies. There is documentation where one of the major prescription companies literally was saying that these medications were either not addictive or had an extremely low rate of addiction.
An article in the Wall Street Journal in early 2000 reported that there was a guide put out by the Joint Commission. With it being quoted as stating “some clinicians have inaccurate and exaggerated concerns about addiction, tolerance, and risk of death. This attitude prevails despite the fact that there is no evidence that addiction is a significant issue when persons are given opioids for pain control”.
The narrative that was being presented on all sides from the Joint Commission to the pharmaceutical companies, was that the risk of addiction, tolerance and death was low. That any doctor who was found to be allowing their patients to linger in pain would be subject to sanctions.
Around the same time pain was listed as the fifth vital sign and the American Pain Society is behind that campaign slogan. The Veterans Health Administration picked up that banner as well.
Standards were issued in 2001 requiring use of the pain scale as the fifth vital sign. The trouble with this is that there’s no objective measure of pain. The other vital signs blood pressure, pulse, respiratory rate and temperature all have objective measures. The pain scale is completely subjective.
Pressure to meet patient demand placed on prescribers
Another factor is that during that same time patient satisfaction surveys were being done and sold to different organizations as an example of things that patients say and feel about their medical experiences. So we have doctors at the center of this. They have pressure from the higher ups to make sure that patients are satisfied.
They have the threat of lawsuit and sanction if they don’t treat pain appropriately. They have patients reporting pain on widely varying experiences. That leads to widespread prescribing of opiates for pain management. This practice continues and the rate of overdose deaths as you can imagine, is going up.
There were definitely doctors doing shady shit, such as “pill mills”. These are doctors who would set up shop, take cash only and prescribe any kind of medication for whatever ailment. One of the doctors talked about a bold doctor in his town who would meet people at the local coffee shop to exchange prescriptions for cash.
When there’s money involved, there’s going to be corruption involved. The majority of physicians though, we’re trying to do their due diligence. Yes, they are the ones who signed the prescription pads. Doctors know that they were the gatekeepers and they were dealing with misinformation and outright lies. Not to mention pressure. Doctors are not immune from the pressure from the agencies and hospitals they work for.
So around 2010, we have the crackdowns starting on the prescription of opiates. This is where the second wave of opioid overdose deaths starts. I can only speak for the area of the U S that I live in, and I know that opiates are a problem in other countries. Some European countries were able to avoid this because their doctors weren’t paid the same way that they are in the U S or in Canada. So Canada and the US are both fighting the same epidemic.
I recall a couple of things happening in the hospitals, around where I live. One thing was that all of a sudden drug representatives were no longer allowed to bring in catered lunches, swag with the pharmaceutical name on it or do presentations for the staff. One local hospital rounded up every single piece of paper, post-it note pad, clock, mouse pad, tape dispenser, stapler remover, signs, pamphlets, everything that had to do with various drug companies. They put it all together and shipped it to frontline clinics in third world countries. Now none of that stuff is allowed.
While I agree that it shouldn’t be allowed, a downside is there’s way less samples available for people to have as medications. I remember having a lot of samples as a kid when our insurance didn’t cover something specific.
The idea was that the pharmaceutical companies had an undue influence over doctors and their prescribing habits. There was finally research to show what we knew: subliminal messaging and being confronted with a name of a medication over and over, kept it on a doctor’s mind and seemed to influence their prescribing habits.
I can 100% see that happening. We are not immune from things around us. The reason that advertising puts their name all over everything is because we’re taking in that information, whether we realize it or not. Once the research came out, hospital organizations, clinics, other agencies felt like they were compelled to say, Nope, we’re not going to prescribe like this, and we’re not going to allow ourselves to be bought.
Of course, people who are benefiting greatly from the way business had been done. There were many medical and mental health professionals who benefited personally and financially from drug companies. This is part of the reason that whenever you go to a training, people tend to say that they have this sort of conflict of interest or who’s funding them and it all comes out of this crackdown, which I think was needed.
The second part of this crackdown around 2010, was that prescriptions for opiate medications dried up. If the problem was over prescribing, then the answer is don’t prescribe. All of a sudden you have panels of patients who have been taking opiates for 10 or so years and they are now physically dependent on these opiates. They are not able to just get off of them.
Pills were being given out in large quantities and for most people who were taking them they weren’t getting addicted. They were leaving them in their cabinets. I remember there being Codeine and Valium, some other stuff in our cabinet, just hanging out. Lots of people had that. We would hold onto medication, sort of like a, as if thing, even though we were given instructions to not just randomly decide to take medication.
Some people got huge amounts of medications and if someone else needed them, you’d give it to them. The majority of the prescription medications in circulation we’re coming from legal means, but being sold or given by people who got them from a prescription. It’s really common when somebody is dependent on painkillers to find someone around you who also has had them and trade for them or buy them or whatever.
There are people who use that as their source of income because they’re disabled or because they have chronic pain and can’t work or in other ways, need money. This is not a way of necessarily getting rich. Getting pills is the kind of thing that you never know how much is going to come through.
Opiate withdrawal drives the rise of heroin
So now we’re in 2010/2011, and the pills are drying up all over the place. Of course, there’s more coming in from major cities, but they don’t have a factory that’s creating these things for them. We have a lot of people who are dependent on opiates and they start going through withdrawal.
When I say withdrawal from opiates there are people who may not know how incredibly terrible it is. It is pain beyond anything you can imagine. Yes. Even beyond childbirth.
One of the main things that the overuse of opiates did for people was cause hyperalgesia. Hyperalgesia is an extra sensitivity to pain. So painkillers made people’s pain tolerance go down and not just because they were treating their pain, but because now they are truly more sensitive to pain than they were before they started taking opiates.
So when I say that the pain from opiate withdrawal is the worst thing that is compounding that factor. It’s like the worst flu times a hundred. People feel like their bones are on fire all over their body and shattering from the inside and this lasts for days. There’s nausea, vomiting, there’s sweating, there’s body aches and chills . The withdrawal is awful. This is not something that this community of people had ever really experienced.
The pharmaceutical companies were targeting average people who were having some sort of surgery routine or otherwise. They’re targeting people who would be more likely to be at a doctor’s office. People who are using drugs typically don’t end up in a doctor’s office unless they’re in the ER, because they can’t avoid whatever’s happening. Otherwise they absolutely avoid the doctor.
So we’ve got these people, all of a sudden who are being cut off their medications, sometimes without any warning and it’s done and they’re in the throes of withdrawal and they’re desperate. People who would have never guessed that they would become addicted or that they would ever try to find drugs or pills on the street are all of a sudden having to do just that. It wasn’t just the doctors that were being told that this medication was low risk. Patients also had this information.
One of the main culprits Purdue Pharma, the makers of Oxycontin. Oxycontin is a pretty serious opiate in terms of potency. Someone might’ve started out with Tramadol and then Tramadol isn’t working quite as well. And then we go to Lortab, maybe 5, maybe 7.5’s and then to 10 milligrams, and then that’s not working quite as well. Then we go to Oxycontin and you’re having to increase the dose of Oxycontin.
You’re having to take it more often. You’re having to take it in higher quantities. Otherwise the pain is excruciating and it’s that simple. Nobody ever plans to be an addict.
People don’t sit around thinking, you know what? I’m going to totally fuck my life. And I’m going to get addicted to this shit so that I ruin everything or I’m going to make this so I have to be in excruciating pain and always be afraid of withdrawal every day. That is never what happens.
I know that it sounds ridiculous. Like we would never think that happened. But there seems to be this undercurrent that people feel like, well, it was their choice. No, they didn’t choose addiction.
They chose to have relief from pain. It could have been emotional or physical. That’s what they were choosing.
The thing about those pills is that they’re effective. Let’s say you’re a stressed out parent and you have some sort of minor injury that happens to those of us in “midlife”, you get some pain medications and it helps. That relief from pain. There’s nothing like it. There’s no feeling quite like pain receding from your body when you’ve been suffering.
Then you figure out that as the days go forward, that your incredibly stressful life isn’t quite as stressful. Yeah, you’re having some pain. So you take one and this is how it goes forward. You aren’t thinking about hyperalgesia and the fact that you’re going to get more sensitive, you probably don’t even know that. You aren’t thinking about what would happen later.
All you’re thinking about is the day that is in front of you and trying to manage the stress of working, of taking care of kids, being in a relationship, aging parents or whatever the case may be. It dulls the edges. The tolerance happens really, really fast.
No one is immune to heroin’s pull
For some people, maybe it took years, for others it’s a few weeks. The messages being sent were that if you took pain medications as prescribed and you took them only for pain management, that was okay. That somehow your body would, I don’t know, know that you weren’t trying to be an addict and wouldn’t become one.
I’m not really sure how that logic worked. What I know is that the outcome was that we had a ton of people dying from overdoses and that when they took away the pills, all of a sudden heroin walked back into the scene. It was never truly gone, but it was sort of relegated to different parts of society and not necessarily in the mainstream. Heroin is way cheaper than opiates.
I know that there are people who can’t imagine the idea of using heroin; that it is super beyond them. If you are facing the worst pain of your life and you can spend hundreds of dollars on pills and have to wait and figure out how to dole them out to yourself so you don’t get sick or an incredibly cheap amount of heroin. That is a no brainer. Now some of you might have better resistance than others who knows.
I know that nothing quite changes your mind, like pain. It’s why torture is a thing. Maslow’s hierarchy of needs, right? Safety, security, food, shelter. Those are the things that we need and when your body is in pain, you can’t think about other things. That’s why self harm works so well. Not saying it’s adaptive, I’m just saying that it works.
I always use this as an example up here in the North country, because Lake Superior is frigging cold. Like all the time cold. You might be able to swim in it in August, but it is not warm by any stretch of the imagination. Standing in Lake Superior trust me when I say you are not thinking about anything else except holy shit. I’m freezing. That’s it. You can’t think about what about my future? How do I feel about my ex? Do I feel depressed? Am I happy? Do I like my life? No, no, no. You’re thinking about, I got to get warm.
That’s the same thing that happens when you’re in pain. Everything in the future, everything in the past and on the sides tunnels until all you feel is pain. .
That begins the second wave of overdose deaths because of switching to heroin. Heroin is more potent than what they were using. There’s no “dose” for heroin. You don’t know how much you need to take and in addition, it’s not regulated in the slightest. You have no idea what’s in it.
Drug dealing is about making money and so if there is a way to make drugs go farther, then they’re going to do that. Heroin is synthesized from naturally occurring compounds. There’s a limit on how much you can create of actual heroin based on what’s growing. Drug dealers found a way to spread the heroin farther, and that is fentanyl.
Now, if you recall, when we talked about levels of drugs and potency, fentanyl is at the top. Fentanyl previously was used usually in patch form and this is typically for end of life stuff. This is not something that we use for someone who’s having surgery or some other kind of procedure. This is for someone who is basically dying or going to die quite soon.
So if you take fentanyl as a powder and mix it with heroin, they are indistinguishable. All of a sudden we have people dropping dead from heroin because there’s fentanyl in it. They went into respiratory arrest and they unintentionally overdosed. You can definitely overdose on heroin that’s just straight heroin. People absolutely die all the time from that. The introduction of fentanyl though increased our overdose deaths many, many fold.
Opiate overdose can be relatively silent. Opiates are a depressant. They slow down your central nervous system. They slow down your respiration, your heart rate, all the things attached to your central nervous system and they don’t hit you and then decrease in potency. Most of these pills are meant to be extended release or released slowly over time to help maintain pain management. So if someone’s using heroin and they take whatever their “dose” should be, and they don’t know what’s in it they might not know they’re in trouble. Because what happens is they end up nodding out.
When I say nodding out, if I were to describe it, it sounds like they have narcolepsy. Like they’re just sitting there and all of a sudden their head drops and it’s not the same as narcolepsy. That’s a completely different function, but they will nod out mid-sentence. They’ll be talking and then bam- out. Then they’ll wake up and be like, Hmm. Eventually people just pass out. They fall asleep.
What is the thing that we are told to do when somebody has had too much of something, typically it’s drinking, but people use this kind of logic and advice even when it’s not alcohol, they’re told to sleep it off. Well, a person goes to sleep. They’re quiet. They’re not being obnoxious or showing signs of distress. So people let them sleep. What happens is called respiratory depression, their breathing slows down, their heart rate slows down and their breaths grow fewer and farther between until eventually they stop breathing totally.
In order to save someone from an overdose, you have a very short window to find them. Typically if someone’s using, they’re using it with other people who are also not in their right frame of mind. Overdose deaths are typically accidental. Yes, I am certain, there are people who use them deliberately. We won’t ever know those numbers.
This is the path that took us from the doctor’s office all the way to overdose and it’s how we created a new type of addict. Not one that had been using all their lives, but ones who became addicts after a surgery or a procedure.
There are still people who are still using opiates in some form, even though the crackdown started more than 10 years ago. There are people who are still stuck in this. Of course, pills are harder to get. Any one of us who has had to have a procedure or something done knows that we’ll get a tiny amount of pills and have to call for more. It can be really frustrating because doctors, rightfully so, are on their guard. People come up with crazy stories to try to get pills. Not because they are deviant, but because they are addicted.
This is the first part of information I feel like we need to know as therapists. The next part is going to be a little more practical. I want to talk about how pills are used, how they’re injected, why someone would be switching and different information that comes from actual lived experience for someone who has used those drugs.
That’s going to be the second part of our series. I know this is heavy stuff and you wouldn’t be listening if you weren’t interested. And so I’m hoping that you’ll join me next week. When we keep talking about opiates and heroin.
Have a great week.
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