Siobhan Reynolds’ most recent guest post to this blog does an outstanding job of making the case that we (meaning both society writ large and the medical profession more generally) have utterly failed to address problems of chronic pain, and that these failures have a great deal to do with “the context of drug prohibition.” Reynolds observes: “The system-wide denial of humane and effective treatment is covered up by the fear campaign that has been hammering away at our consciousness since the dawn of drug prohibition–a fear campaign masquerading as a public health initiative.”
The phrase “the dawn of drug prohibition” led me to ask myself–just what are the roots of our contemporary struggle to employ opiate analgesics effectively and appropriately, and how deep are they? Here’s a bit of what we, as historians, know about the case of the United States.
1) All the time and attention paid to “dope fiends” and illicit recreational use of opiates before and after passage of the Harrison Narcotic Act should not obscure the fact that, from the beginning, concerns about the overuse of opiates in medical practice (generally, and not simply on the question of maintaining addicts) were fundamental to the war on drugs. Organized medicine, and many individual practitioners, embraced the cause of fighting excessive opiate prescription (while the federal government launched its research quest for a nonaddicting analgesic). As Caroline Acker put it, in her comprehensive account, Creating the American Junkie [p. 74]: “Educating physicians to reduce medical use of opiates by observing narrower indications for their prescription, reducing doses, and replacing them with newer, more specific drugs was part of the AMA’s campaign to distance physicians from association with improper use of opiates more generally and from addicts specifically.” (1)
2) The war on drugs has always been, in part, a war on doctors. Early educational campaigns designed to encourage voluntary changes in prescribing habits were accompanied by far more aggressive measures designed to control physician behavior. Some years ago, in a piece titled “Building a Drug Control Regime, 1919-1930,” I examined some enforcement data from the early years of the federal drug war.(2) The subject of Harrison Act cases were distinguished as “registered” and “unregistered.” Without belaboring the point, “registered” meant registered under the Harrison Act, which meant physicians, pharmacists, dentists, veterinarians, drug wholesalers, importers, and manufacturers–while unregistered generally meant users and sellers outside of the medical-pharmaceutical network. (3) Dipping briefly into the numbers, let’s consider Harrison Act cases for 1926. That year, the federal government convicted 4,835 unregistered persons against only 223 convictions of registered persons. The number of convictions of registered persons that year was about what it had been back in 1919, while convictions of unregistered persons had risen fourteen-fold in the same period. Was the federal government avoiding doctors in its enforcement efforts, turning its full attention to the street-level illicit market? Not at all. Closer inspection of the 1926 numbers shows something quite interesting. That year, 6,411 formal prosecutions were initiated against registered persons. 2,807 (43.7 percent) were “pending” at the end of the year; 1,409 (22 percent) were dropped; and 1,965 (30.7 percent) were settled by compromise, leaving just the remaining three percent as convictions and acquittals. What was going on? Effectively, federal agents were warning medical and pharmaceutical practitioners. Cases could be started and dropped to send a message, and “compromises” were essentially settlements of cases through the payment of a fine. These “compromises” had become so widespread in the 1920s that even the AMA’s legislative counsel was moved to condemn the “distress and humiliation” faced by a physician who “must either compromise his case or go into a public court room and defend himself, with the possibility of spreading the suspicion that he is a ‘dope peddler.'” (4) Thus, while part of the story involves professionalizing medical fields embracing the idea of curtailing opiate prescription, the drug war aggressively pursued doctors and druggists who did not. One simply cannot overstate what kind of an impact these years of enforcement efforts had on the medical profession.
This much, I think we know. There’s a great deal more to be learned, however. How much could be learned, to take just one example, by digging deeper into that Harrison Act enforcement data, to see what kind of doctors were being targeted, and what kinds of prescribing behavior led federal agents to step in? My guess is that these cases would show us the foundations of the contemporary muddle that Siobahn Reynolds has so well described.
(1) Caroline Jean Acker, Creating the American Junkie: Addiction Research in the Classic Era of Narcotic Control (Johns Hopkins University Press, 2002). Acker’s obervation about the acquiescence and participation of professional organizations in the drug war project is quite right–I observed much the same thing with respect to the early history of cocaine (and of course, David Musto’s classic work shows the point more generally as well).
(2) Joseph F. Spillane, “Building a Drug Control Regime: 1919-1930,” in Jonathon Erlen and Joseph F. Spillane, eds. Federal Drug Control: The Evolution of Policy and Practice (Haworth Press, 2004).
(3) Readers may be wondering if doctors or druggists could be among the “unregistered” group. They could, and were, but not many. One measure is educational background–federal data on unregistered arrestees in this period shows fewer than 1% holding professional degrees of any kind.
(4) The complaint was registered at a hearing of the House Committee on Ways and Means, Bureau of Narcotics, 71st Congress, Second Session, 1930. There’s more detail in my chapter cited above (see note 2). It would be helpful for some future study to investigate the post-1930 enforcement activities of the Federal Bureau of Narcotics under Harry Anslinger, with respect to doctors and druggists.