Do No Harm: Initial Prescription Details Influence Chance of Opiate Dependence

By Terry Gotham

One of the biggest problems with writing about the War on Drugs is the almost exclusive focus on problems. There’s this myth that drug use is a combination between a ratchet & Russian roulette. It’s going to keep getting worse, and it gets harder and harder to “not be addicted” the longer you do it. This continued narrative is believed widely (just ask your family at Easter dinner), while being only lightly supported with evidence. Harm reduction & physician/client education is surprisingly effective at mitigating a lot of the factors that contribute to this “it’s probably going to kill you” problem, but outside of needle exchange/safe injection sites & drinking water while partying, complex harm reduction ideas rarely make it into non-academic circles. So, I’m going to start talking about constructive, modern ideas and research that have been either theorized, published or put into practice, about how to fight this deluge.

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Cannabis and Kratom: A Light in the Opiate Dark

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Analysis by Terry Gotham

With the country currently gripped in fear that ACA will be repealed, I’ve started to ponder what options will be left for Americans in the throes of physical dependency if the cuts to medical/addiction funding are as deep as the ones currently being floated. While some proponents of the 21st Century Cures Act note that there’s been a scheduled $1 billion increase in funding for treatment, a repeal would remove at least $5.5 billion in funding to almost 3 million people suffering from substance use disorders. As dozens of states grapple with ever-increasing rates of opiate addiction and overdose, states that have legalized cannabis have discovered something startling.

A study published in the Journal of Pain by a trio of researchers out of the University of Michigan documents a reduction in opiate consumption in Chronic Pain patients who use cannabis. Specifically, medical cannabis uses was associated with a 64% reduction in opioid use. Additionally, 45% of the patients (118 out of the 244 sampled), reported reduced side effect frequency & intensity. In states that have medical marijuana available for their citizens, drivers between the age of 21 and 40 who were killed driving accidents tested positive for opiates significantly less often than drivers of the same age in states that didn’t have medical marijuana available. For example, Montana saw a 1.7% reduction in the number of drivers who tested positive for opioids after their MMJ laws went into effect. And that’s just numbers associated with people behind the wheel. When we evaluate the effect of cannabis consumption on opiate overdoses, the evidence becomes even more compelling.

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Louisa May Alcott: Breadwinner, Frustrated Creative and Opiate Addict

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by Terry Gotham

While I was never that big of a Louisa May Alcott fan, her impact on American literature cannot be denied. Alcott is an adored and fiercely protected author, in no small part because of just how impeccably written and potentially life-changing Little Women can be.  Her eight YA novels have remained in print continuously for the 140 years since they were written. There are two anime adaptations of Little Women, plus half a dozen other adaptations. Her creative output is a fundamental piece of American literature. Today is her 185th birthday, so I wanted to tell you a story about her. You probably didn’t know she smoked hashish and used opium for most of her life to deal with the side effects of mercurous chloride to treat typhoid pneumonia, which is believed to have eventually killed her (though an alternative diagnosis of Lupus was suggested in 2007).

Previously, I was delighted to dismantle the myth that the Civil War created a flood of heroin addict veterans. However, that doesn’t mean everyone managed to escape the clutches of substance abuse. Nurses, doctors and surgeons were far more exposed to the dangers of these substances than the Union soldier who only saw the inside of a field hospital once during his service. Repeated use of alcohol in the form of whiskey and opium in the form of laudanum, morphine, and heroin to treat hundreds of soldiers a week, in addition to essentially zero oversight when it came to use was a one-two punch that created a tempting proposition for those who tended to the wounded on both sides. There are a number of isolated reports, documenting the odd doctor or surgeon who got a little too sauced at work, or needed to be relieved of his duties because he was incapacitated. This implies that there could have been more of these medical practitioners who didn’t get caught, but still ended up using to cope.

Louisa May Alcott, one of the most influential and beloved American writers of the 19th Century, was one of these medical practitioners. She worked under Dorothea Dix who administrated military hospitals as a nurse.   Before leaving for the Civil War, she’d already assumed her station at the head of the household. Her father, one of the pre-eminent thinkers of their day, couldn’t keep it together for long enough to keep them out of poverty. When she left for the Civil War, her father was reported to have said he was “sending his only son to war.”

It was during the Battle of Fredricksburg that she contracted typhoid pneumonia, an ailment that would alter her life forever. The prescription for typhoid was calomel, and to ease the side effects of literally consuming mercury every day, she started using opium, in the form of morphine & laudanum. She didn’t enter into this habit by accident. She was a very smart lady and knew the potential dangers in consuming it daily. Alcott assisted Catherine Beecher in writing The American Woman’s Home in 1869, a year after Little Women was published, in which she stated:

“The use of opium, especially by women, is usually caused by at first by medical prescriptions containing it. All that has been stated as to the effect of alcohol in the brain is true of opium; while to break a habit thus is almost hopeless. Every woman who takes or who administers this drug, is dealing as with poisoned arrows, whose wounds are without cure.”
~Alcott & Beecher, The American Women’s Home (1849), revision of A Treatise on Domestic Economy (1841)

But a little thing like typhoid pneumonia & a daily opiate habit didn’t stop her. She built herself into the powerhouse of an author by sheer force of will. Realizing that her success and financial stability was depending on her career as a writer, Alcott built herself and her writing into a brand that we remember to this day. While she had made money previously from writing pulp fiction, this was light years away in propriety from Little Women and the branding and recognition that followed. The pulp was published anonymously or under a man’s name (A.M. Bernard) for similar reasons to why women writers today publish using a man’s name.

By 1870, she had grown so dependent on opium that she no longer expected to be able to sleep without it, as she described at the end of this letter to her father:

Our hotel is on the boulevard, and the trees, foundations, and fine carriages make our windows very tempting. We popped into bed early; and my bones are so much better that I slept without any opium or anything, a feat I have not performed for some time.
~Louisa May Alcott to her father, Hotel D’Universe, Tours, June 17,1870

As discussed in the Seattle Pi article that I’ve cited a few times, it’s important for stories like this to be told. Not because I think famous people should be knocked down off their pedestal, but just the opposite. We treat substance use/abuse as almost integral to the creative process, especially when it comes to strong drink and writing. This seems to be heavily amplified in men while minimized in women. The idea that alcoholism is this noble part of the developing male writing process has been so deeply embedded in the work that I have friends who honestly didn’t pursue significant study in writing because they were Irish and didn’t want to fall in love with Jameson. This is going on while we eulogize female writers in the exact opposite way, discussing them as pure or without stain, objectifying them in hugely problematic ways. Then, when someone like Amy Winehouse, Billie Holiday or Janis Joplin struggle and die from drugs, we pretend there was nothing we could do and that it just “happened again.” That needs to stop. As a dear friend reminds me, we celebrate drug use in men and totally ignore it in women.

Creative women are no different than creative men and their processes should be laid bare for all to see, scars and stumbles included. Louisa May Alcott probably pursued her habit away from her family or those who could help her. Given her status as the household’s main income generator, I think it’s easy to see her habit in line with the alcoholism of Don Draper, or the cocaine usage of a street dealer. They use because they have to, in order to provide for the people they love. Louisa May Alcott was able to produce Little Women & Perilous Play, a story about hash, in the same year. That’s nothing if not professional. She inspired generations of women to be better than the brand she created. Which is the point of art in the first place. She may not personally be this amazing protagonist hero that she write about, but in striving to be so, even if it’s only to feed her family and take care of your idealist, lazy ass family, she created the possibility for those who looked up to her to become exactly that. As a biographer of hers said on NPR: “You don’t grow up to walk two steps behind your husband when you’ve met Jo March.”

Morphine, Myth & The Civil War: Before Cause and Effect

Editorial by Terry Gotham

Last week, we spoke about the gendering of drug use in America and how that may have led to the original wave of drug prohibition laws. This was one example of the  many times where drug use was distorted as a justification for it to be outlawed. One of the biggest myths associated with heroin usage was that the Civil War “created 500,000 addicts.” This is of course not the case, so let’s unpack the various reasons brought up to justify this erroneous attribution. An exceptional paper published in War In History by Jonathan Lewy of Harvard University helps to round up the main reasons this assumption is wrong, which I’ll be quoting from liberally.

One of the easiest ways people explain the deluge of opiate & whiskey addicts during the last quarter of the 19th century & the first 2 decades of the 20th was the invention of the hypodermic syringe. The Civil War doctor did use opium for much more than just killing pain. Opium was used for diarrhea, dysentery, stomachache, gallstones, hemorrhoids, tetanus, typhus, syphilus & “neuralgia” (an anachronistic diagnosis that loosely translates to peripheral neuropathy today). But, remember, it’s 1860. Opium powder was usually sprinkled on top of the wounds suffered by soldiers in the field. By the end of the Civil War, a little over 2,000 hypodermic syringes had been fabricated & distributed to the 11,000 surgeons employed by the Union Army, which is one of the pieces of evidence used to support the claim that the modern heroin addict was created by the Civil War.

There’s one crucial difference between a modern syringe & those that were used, especially at the beginning of the Civil War. The first syringes were dull. That’s right, doctors had to puncture your skin first using a lancet (yes, that’s where the journal name comes from), before using the dull and large gauge syringe to deliver the medicine. So, the most hyperbolic claim, that soldiers were shooting up because they were taught to do so at field hospitals and by doctors, can immediately be dismissed. If any of you had nightmares that involved Requiem For A Dream and civil war uniforms, you can put that aside.

Not only was injection drug use essentially impossible, Confederate surgeons had little to no access to spare opium. The Confederacy attempted to grow poppy fields to supply their armies with opium. This sounds like a good idea in theory, but resulted in exceptionally poor quality poppy crops and an inferior supply of pain killers for the Confederate Army. Resulted in the Confederacy relying on smugglers & blockade runners to bring it down from the North, as one of the first examples of drug running in the USA.  The North was buying opium on the world market, as their Navy gave them access to trade with Europe. And boy did they take advantage of that. The Federal Army consumed 10 million opium pills and 80 tons of opium powder & laudanum tinctures before the surrender at Appomattox was signed.

People weren’t converting pills into inject-ready substance in the field, and the Confederacy couldn’t even get its hands on syringes and medical staff/training using them. When you’re taking a small pile of opium and spreading it over a wound with a knife, the person receiving care doesn’t know they’re “doing heroin.” It’s hard to develop a drug habit when you don’t know what drug you’re craving.

There were anecdotal cases of physicians becoming addicted to the morphine, but as a record, this was always classified as misuse, not addiction. General Benjamin Butler discovered one such doctor, and relieved him of his duty. However, no note of addiction, health problems, or vice was mentioned, merely a note of dereliction of duty. This is corroborated by The Medical & Surgical History of the War of the Rebellion, a six-volume epic tome documenting the case histories of the various field surgeons across the US Army. 13 years of records were submitted, accounting for all of the ailments, diseases and afflictions that these doctors, surgeons and field hospital directors encountered. Zero cases of addiction, or anything resembling the modern, conventional definitions of substance abuse/addiction appear.

This isn’t to say that the maladies associated with excess substance use weren’t known. But the idea that the substance use, if continued, would cause dependence or other negative consequences, hadn’t entered the greater medical world, and wouldn’t for years. The Manual of Military Surgery, introduced in 1861, noted that morphine & laudanum (tincture of 10% opium in alcohol) should be used in managing pain and amputation-related hardship. Interestingly, and without further definition, the reader is warned to not abuse the drugs “lest they induce fatal oppression of the brain.” For serious, no other context is given, you can see for yourself on page 50:

“Reaction must be promoted by the cautious use of stimulants ;while pain is allayed by morphia orlaudanum given with more than ordinary circumspection, lest it induce fatal oppression of the brain.” ~Samuel Gross

Could “fatal oppression” be like our modern definition of “brain death?” You betcha. Will we ever know if it was, definitively, and not the fog, memory loss or other neurological side effects of opiate use described at the time? No, which is a huge problem. It’s really easy to assume, but we need confirming evidence and there simply isn’t any. And, to put this lack of information in context, in the late 19th Century, the closest thing to “addiction” most people were aware of was the “habit” (Source Bias warning: Vaguely pearl clutchy, but still relevant historical portrayal of the time).  Alcohol had been seen to be habit forming as early as 1819, but morphine wasn’t seen in the same light. Using opium was seen as roughly equivalent to swearing, paying for sex, gambling and gossiping. If you couldn’t resist the temptation of drink or poon or dope, you were a sinner, or morally weak, not sick. But in 1877, 12 years after the end of the Civil War, that changed. Die Morphiumsucht was published by Eduard Levinstein, connecting drug use with a craving for more drugs, for the first time in the wider, respected medical literature. And I do really mean for the first time. Between 1864 & 1875, when Levinstein lectured publicly on the topic for the first time, only 24 articles discussed pathology stemming from drug use. In the decade after? Over 230. It’s kind of hard to have a mass of people “addicted to drugs” when they couldn’t access the drugs, and “addiction” wasn’t a word at the time. Oh, and the people weren’t there either.

The USA documented approximately 10,000 habitual opium uses (referred to as habitues) in 1842, with that number peaking at 313,000 in 1896, according to some. However that number gets turned on its head when it’s documented in the same source that there were more women habitues than men. Grief caused by becoming a widow explains why all the women are getting high, but, if all of the soldiers are dead, where is the epidemic of strung out veterans? They weren’t in the Sanatoriums, as a casual review of the Second Annual Report to the Citizens in the Delaware County American shows. Even back in 1868, right at the end of the war, when soldiers were most vulnerable to opiates, 2 out of 26 under his care, were there for opium. The rest? Booze. Additionally, they were in there because of social use or physician prescription, not because they even fought in the war. In the “National Homes” in and around Milwaukee,  only one veteran was admitted to the entire system for non-alcoholic drug use between 1867 & 1872. To put that in perspective, 36 people have died from Fentanyl overdoses alone in Milwaukee this year

Were there people who developed habits? Absolutely. The Confederate vet Doc Pemberton was wounded at the battle of Athens, Georgia and became addicted to cocaine after being given it on the battlefield. After the war, as an unemployed chemist, he created a brew of cocaine and kola nut extract, as an attempt to keep up with the hooch being slung at the saloon across the street. Were there a giant pile of strung out drug addicts walking around after the war? No. What were there? A bunch of wounded veterans.

Lewy really does sum it up quite nicely in his conclusion, so I won’t try to out do his words:

Some contemporaries claimed their experience in the war prompted their addiction. A few decades later, Crothers and other physicians supported the notion that the war caused addiction, but not based on fact, at least statistical fact, but was due to the understanding that wars caused trauma. One can only assume that, with the amount of drugs consumed by the armies of the Civil War, a few soldiers and perhaps even a General or two became addicted to drugs, but it would be next to impossible to determine how many (were), and whether this was, indeed, a historical trend. Especially since addiction was only recognized as a full fledged disease several decades after the war.
~
Johnathan Lewy, The Army Disease: Drug Addiction and The Civil War (2013)

Finally, it’s important to note that this fear of drug zombie veterans have been used as a justification for drug laws ever since. A heroin resurgence coincided with the end of World War II, the Korean war sparked rumors that Communists were attempting to dope American youth to beguile them, Vietnam managed to vilify drafted soldiers, decrying their drug habits before they even returned, and the war in Afghanistan is already being blamed for heroin use among soldiers. There will always be people attempting to justify drug prohibition using the trope that veterans would be the most vulnerable of American citizens. Yet, this continues not to be the case, even to this day. Don’t believe the hype. Drug use is an ineffective, yet popular way to cope with trauma, whether you were part of a unit that saw incoming fire at the Battle of Gettysburg or if you’re just growing up in rural America after Bain Capital sent all of the jobs in your town away.

W-18: A Novel Opioid The Media Is Getting All Wrong

By Terry Gotham

I try not to use Burners.me as a megaphone, but as I read about this substance & how it was being covered in the media, I needed to make an exception. To be clear, we have no evidence of this substance being found or consumed at Burning Man, but I believe it will become a problem in the painkiller consuming community on the West Coast over the next 18 months. W-18 is a novel analgesic that was patented as the 18th in a 32 compound series by a trio of Canadian researchers in 1984. First flagged by the European Monitoring Centre for Drugs & Drug Addiction in 2014,W-18 started turning up in prescription oxycodone pills seized by Canadian law enforcement in early 2015. It’s been banned by China, but the reasons why are unclear. The news stories on it started to pile up in April, so started digging. I found two scoops of sloppy reporting and a shocking lack of real information.

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