Chapter 2
The Search for Better Health

The history of medicine is the history of a quest for better and more certain means to treat disease and pain. Modern physicians readily admit that until the early 1800s science played only a minor role in curing diseases. Before then, thousands of patients suffering from a variety of diseases were treated with baseless cures often dating back to the Middle Ages. Physicians recommended unscientific and often ineffectual treatments such as purging the body by inducing vomiting and diarrhea, removing "bad blood" by placing leeches on the patient's skin, and "balancing the body" with a variety of traditional herbal remedies.

In the context of this historical backdrop, the discovery of opium's analgesic and possibly curative properties caused optimism to soar within the medical community. Finding cures for many common yet life-threatening diseases was suddenly a real possibility. The few people who studied and wrote about opium believed that it had the potential to become the panacea drug of the nineteenth century. As research and time pushed forward, scientists committed their energies to understanding opium's effects on the mind and body. Slowly and shakily at first, a solid body of medical knowledge emerged by the end of the twentieth century.

Early Medical Applications

By the mid–nineteenth century, many physicians viewed opium as a medicine rather than as a recreational drug. Opium had become an accepted part of medical practices, even though British and American physicians had only a rudimentary understanding of its effects on the body. Illustrative of the confusion of the time was a debate over whether the drug possessed stimulant or sedative properties. It was not until the twentieth century that opium was correctly identified as a sedative.

Of greatest interest was the medical application of opium as an analgesic during and following surgery and for patients with painful yet inoperable diseases such as advanced cancers. Other rudimentary analgesics and anesthetics—substances that totally block pain temporarily—nearly killed the patient in order to be effective. Opium, however, became prized by physicians because in controlled doses it alleviated pain while allowing the patient's body and mind to function properly.

Opium was used as an anesthetic during surgery. The science of anesthesia would not originate until the early twentieth century, when gases such as ether and chloroform were discovered. Until their discovery, the sedative effects of opium, which was administered in higher doses for surgery than for pain relief, partially worked to anesthetize patients. Great care was given in determining the dosage, because physicians understood that an overdose would suppress respiration and kill the patient.

Opium as an anesthetic and analgesic was heralded as one of the greatest medical breakthroughs of its time. In the 1850s, medical research facilities conducted extensive chemical analysis on the content of opium sap and discovered a variety of compounds responsible for reducing pain. Doctors and pharmacologists recognized that millions of lives could be saved using opium to sedate patients during surgeries because longer and more complicated surgical procedures would be possible. Within ten years, compounds containing opium were being manufactured into pills for medical use. In the 1860s, during the Civil War, Union army physicians used opium during surgeries for amputations, internal

wounds, and shrapnel removal. They also issued an estimated 10 million opium pills to soldiers recovering from surgeries.

Following the war, doctors heard about opium's success on the battlefield and envisioned more applications. Stories about opium's ability to relieve pain without debilitating the patient attracted obstetricians concerned with the pain of childbirth. Women welcomed the relief they experienced with opium while delivering healthy babies. Opium also proved helpful in relieving the intense pain of patients suffering from third-degree burns or undergoing cleft palate operations, nose and throat surgery, or tooth extractions. Oncologists prescribed it to relieve the severe pain experienced by patients with incurable forms of cancer, and cardiologists used it on patients suffering from heart disease because of opium's ability to calm and quiet victims.

Researchers experimenting with opium further discovered that the drug caused constrictions of the intestinal lining, reducing fluid loss associated with diarrhea. Diarrhea, which contributed to a victim's death by causing acute dehydration and loss of vital chemicals, was a symptom of such deadly diseases as malaria, typhoid fever, dysentery, and yellow fever.

Doctors soon were hopeful that opium pills might cure a wider range of diseases. They prescribed opium for anemia, insanity, tetanus, and a variety of complaints associated with pregnancy. Physicians were so pleased with opium that they referred to it as "GOM," meaning "God's own medicine."

Commercial Value

Shortly after physicians discovered the medicinal value of opium, pharmaceutical companies saw it as a gold mine. Bypassing doctors, they marketed syrups and powders laced with opium directly to American families to soothe everyday aches and pains. By the early 1900s, use of opium in commercialized products exceeded its medical use.

One of the most popular commercial items were opium-fortified teething powders used to tranquilize crying babies who were cutting new teeth. Prior to the availability of opium, all teething remedies were alcohol based; ignorant of any possible side effects of opium, mothers gladly substituted it for alcohol. Opium was so successful that pharmaceutical companies sold it as a cure for other childhood medical problems, from earaches and bedwetting to measles, cholera, and diarrhea. Door-to-door salesmen working for Mother Bailey's Quieting Syrup, Mrs. Winslow's Soothing Syrup, and Ayer's Cherry Pectoral sold medicines spiked with 10 percent opium. If mothers were not home, samples were left on doorsteps. The confectionary business soon joined in, adding small dosages of opium, about 5 percent, to candy and sugary carbonated children's drinks.

Adults also enjoyed opium's effects on a variety of aches and pains. Several beverage manufacturers concocted a mix of opium and alcohol and marketed it as a healthful drink. They publicized their health drinks as capable of calming nerves, curing common aches and pains, and imparting a general sense of well-being. At the end of the nineteenth century, a variety of opium-based medicines were cheaper than a bottle of gin or whiskey. For this reason, drinks aimed at adult consumers, such as Battley's Sedative Solution, Dalby's Carminative, and Godfrey's Cordial, became popular drinks for the working class as well as for high society.

Enter the Snake-Oil Salesmen

Once the medical profession had touted the legitimate value of opium for surgery and pharmaceutical companies had filled medicine cabinets with opium-based medicine, charlatans looking to make a quick buck saw their opportunity to jump on the opium

bandwagon. Although these hucksters, often referred to as snake-oil salesmen, had little understanding of medicine, they represented the only medical advice and supply of medicine available to many Americans farming remote parts of the Great Plains behind horse-drawn plows.

Between 1880 and 1920, these opium-laced cure-alls, which were unmitigated shams, were bottled by traveling salesmen and sold to the gullible public. These charlatans traveled from town to town, attending state and county fairs across rural America. They set up shop in the backs of their wagons and trucks and falsely claimed that their medicines were patented and capable of curing dozens of common disorders. The labels on the back of the bottles promised that the contents could cure everything from cancer to measles and even marriage problems. In most cases the contents of the bottle had little curative value and in some cases even inflicted harm. In all cases, it was opium's tranquilizing effect that soothed the buyers' pains and fooled them into thinking they were getting well.

Successful salesmen were great actors, not great men of medicine. Many wore flamboyant theatrical costumes and adopted colorful names, such as William Kroeger, the Priest-Healer of Epiphany, South Dakota; the Texas Outlaw Medicine Men; Indian John; and Daring Dr. Sofie. Guarantees of pain relief and better health accompanied every sale, and the crowds were enticed to purchase by shills planted in the audience who would step forward to testify to their improved health as a result of the bottled medicine.

The men selling opium-laced potions were successful because a couple of swigs from the bottle gave the patient comfort for a few hours. But as the analgesic effect of the opium wore off, whatever pain and discomfort that had prompted the buyer to purchase the tonic returned. Swallowing more of the bottle's contents caused the dazed state to return, much to the relief and satisfaction of the buyer. The labels on most bottles advertised that the contents would bring relief, cause no harm, and save money over more expensive doctor visits. One such label from the 1890s carried this poem:

Never causing any sore,
Causing blood to run or pour,
A bottle costs you fifty cents,
Saving pain and great expense.¹⁸

The Dark Side of Paradise

The reckless proliferation of opium-based medicines, snake oils, and palliative elixirs during the late 1800s and early 1900s gradually exposed users to the dark side of opium. Those hawking opium tonics tended to focus on the relief and pleasure that they provide, but late-nineteenth- and early-twentieth-century doctors had begun to detect and document the agony of those who took increasing doses and some who took too much and died from overdosing. Widespread use of opium in America, its ability to reduce pain yet not cure any disease, and the unpleasant and even painful symptoms that occurred when people tried to stop using the drug prompted the medical profession to upgrade its concern about the effects of opium from worry to fear.

Despite disturbing new discoveries and conflicting views, many Americans consumed opium and most physicians continued to prescribe it because medical knowledge of the drug's properties was scanty and unreliable. Only a smattering of doctors realized that opium use was a growing problem, and few understood why it was addictive or why chronic users experienced withdrawal symptoms when they tried to discontinue or diminish dosages.

At this juncture, the dark side of paradise was beginning to emerge in small medical circles, even though the citizenry continued to believe, mistakenly, that opium was beneficial. Laudanum was freely dispensed to relieve pain and to cure a host of emotional and psychological disorders. Historian Alethea Hayter points out that in the late nineteenth century, "Most doctors and patients still thought of opium not as a dangerous addictive drug but mainly as a useful analgesic and tranquillizer of which every household should have a supply, for minor ailments and nervous crises of all kinds, much as aspirin is used today."¹⁹

Gradually doctors recognized that the core problem with opium use was addiction, the apparent uncontrollable need to be constantly under the drug's influence. To counter what was an obviously growing problem, doctors and pharmacists took on the daunting task of studying and attempting to control opium addiction.

Opium Addiction

Conservative estimates from the early 1900s reported that the United States had four hundred thousand addicts. Initial research established that addiction may take only two to three months to develop, depending upon the method of ingestion; injection was the fastest route to addiction, followed by smoking and then oral consumption.

The medical profession discovered that opium addiction has three stages. The first stage surfaces after some period of regular use when a person requires elevated dosages to produce the same physiological effect. They labeled this stage tolerance, a term that reflects the body's ability to tolerate the drug over time, which means the drug's effects diminish. In the case of opium, the user's body gradually stops experiencing pain relief and the mind ceases to experience euphoric drowsiness when small amounts of opium are consumed.

Chemists discovered two mechanisms for tolerance: metabolic and neurochemical. In metabolic tolerance, the body becomes more efficient at metabolizing the opium and thus the analgesic

effects diminish. During the development of neurochemical tolerance, a realignment in the brain causes permanent changes to brain cells. Eventually the relaxing, sleepy effect of opium is partially blocked. Biochemists explain that when opium dosage is elevated, fewer receptors are needed to absorb the drug. When the number of receptors in the brain declines, the effects of opium are blocked. Later, however, when the amount of opium in the body dramatically declines, there are no longer enough receptors for the brain to function normally.

The discovery of the tolerance stage led to the discovery of the second stage of addiction. During this stage, the opium addict eventually needs more opium to sustain the desired effect. In time, either the amount or frequency of dosages are increased to provide the same relief initially experienced. Typical addicts begin by smoking opium once or twice a week but eventually increase the frequency to four to six times a day to maintain a constant trance.

During the third stage, both physical and psychological dependency occur. Regular opium use renders the addict dependent on

The Opium Rush

When opium is injected or smoked, the peak effects are usually felt within the first few minutes, a sensation known as a rush. The rush, which lasts only two to five minutes, is caused when a surge of opium alkaloids bathe the brain before the opium is distributed and diluted by the bloodstream, filtered out by the kidneys, and converted into other chemical forms that can be metabolized by the body.

The intensity of the rush is a function of how much opium is taken and how rapidly the drug enters the brain and binds to the brain's natural receptors. The rush is usually accompanied by a warm flushing of the skin, a dry mouth, and a heavy, sleepy feeling in the extremities. When the dose is unusually high, a feeling of nausea along with vomiting and severe itching.

For many addicts, the rush is more addictive than the three- or four-hour high that follows it. The intensity of the rush has been described as a pleasurable explosion in the brain, intense sexual pleasure, a state of uncontrollable laughter, and a spiritual experience. In general, addicts report a profound sense of satisfaction, as though all needs have been fulfilled. There is also a state of mild dizziness and a sense of distance or apathy from whatever problems or concerns the user might have.

the drug in order to maintain a satisfactory level of physical and emotional pleasure. The absence of opium triggers physical withdrawal symptoms that resemble an extreme case of the flu accompanied by severe headaches, vomiting, uncontrolled trembling, and a drop in body temperature. Emotional withdrawal symptoms are characterized by an intense desire for the drug, a feeling that the drug is necessary for happiness and contentment and a fear of not having a supply of it. For some addicts, withdrawal also includes nightmares; hallucinations, including sightings of imaginary objects and people while awake; and profound depression that can lead to suicide attempts.

Around 1910, the scientific community was alarmed. It now regarded opium as one of the most highly addictive and debilitating substances known. Chemists and pharmacologists committed enormous resources to discover what was in the opium sap that imparted its addictive quality.

The Chemistry of Opium

The secret of opium's mystical and medicinal properties lay deep within the sticky, milky substance that drips from the incised pods. The first person to investigate the chemical components of raw opium was Wilhelm Sertürner, a German chemist who in 1805 crudely decomposed raw opium paste into a handful of components, one of which was a collection of alkaloids, organic chemical compounds. Sertürner identified a few of the alkaloids that produced opium's analgesic affects, along with many that did not. The alkaloid that was most prevalent he aptly named morphine after the Greek god of dreams, Morpheus.

Twentieth-century chemists, who had the advantage of more sophisticated procedures and equipment, tested raw opium and discovered that its pasty substance was more complex than Sertürner had realized. They discovered sugars, proteins, fats, water, meconic acid, plant wax, latex, gums, ammonia, sulphuric and lactic acids, and many more alkaloids than Sertürner had identified. They identified fifty or so alkaloids, measured their concentrations, and were most intrigued by four: morphine (which constitutes 10 to 15 percent of raw opium), noscapine (4 to 8 percent), codeine (1 to 3 percent), and papaverine (1 to 3 percent). Researchers determined that these four alkaloids were collectively responsible for opium's analgesic value. (One of the alkaloids, morphine, was later used to create the synthetic drug heroin.)

Physicians were excited by these revolutionary discoveries about these alkaloids and by the possibility of using opium to cure diseases such as alcoholism. Of greater interest to the general medical community, however, were the causes of opium's analgesic effects and the intoxicating dreamlike state enjoyed by all who took it. To understand how opium produced these desirable effects, chemists sought the assistance of neurologists, researchers who specialize in the functions of the brain.

Opium and the Brain

In 1972 a group of chemists and neurologists, headed by Dr. Solomon Snyder of Johns Hopkins University, made a puzzling discovery that would illuminate scientists' understanding of how opium influences the brain. They found that the human brain's billions of neurons had specific receptor sites—places where chemicals of various types are absorbed—that have molecular structures very similar to those of several of the opium alkaloids. Because of the molecular similarity of the receptors and the alkaloids, the two combine when they make contact, much like two pieces of a jigsaw puzzle snap together. When they lock up, a process biochemists call binding, the neurons absorb the alkaloids.

This discovery about opium alkaloid absorption suggested to researchers that the brain had evolved to bind with opium alkaloids. But then there was the obvious question of why the human brain would need a receptor for a plant. Further research revealed a likely answer to the question. Dr. Snyder and his team made the startling discovery that the molecular structure of opium is remarkably similar to compounds naturally produced in humans called endorphins. Endorphins are chemicals responsible for pain relief, happiness, and relaxation. Some of the opium alkaloids, particularly morphine and codeine, mimic high levels of endorphins, relieving pain and producing a heightened state of well-being.

The Role of Endorphins

Pharmacologists performed additional research to understand the biochemical mechanism that allows opium and endorphins to produces their pleasurable effects. An endorphin is a special chemical called a neurotransmitter, which has the job of transmitting electrical messages from one neuron to the next. Endorphins flow from neurons into the synapses, the tiny spaces between neurons, to form temporary bridges that carry electrical signals across the synapses. Normally, after a neuron has transmitted its signal to the next neuron, the endorphin exits the synapse, returning to the same neuron that released it in a recycling process called reuptake. However, if opium is present while an electrical signal is taking place, scientists believe the opium blocks the reuptake process, resulting in a buildup of endorphins in the synapse. As the buildup of the endorphin neurotransmitter continues, any pain or discomfort experienced by the user is relieved and a peaceful dreamy sensation is experienced.

According to Dr. Snyder, "Like an evil twin, the opium molecules lock onto the endorphin-receptor sites on nerve endings in the brain and begin the succession of events that leads to euphoria or analgesia. This imposter is more powerful than the body's

Opium Withdrawal

Opium withdrawal is the emotional depression and physical distress that sets in three to four hours after a user experiences the euphoria of the opium rush. Withdrawal occurs because the body and mind have adapted to the presence of the drug and withdrawal symptoms arise when use is reduced or stopped.

Initial withdrawal produces a craving for more opium, restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, sneezing, a runny nose, and chills with goose bumps—the last of which gave rise to the term "cold turkey," meaning an abrupt abstinence. Muscle spasms, produce kicking movements, from which came the term "kicking the habit," meaning eliminating the habit. Major withdrawal symptoms peak between two and three days after the last dose and subside after about a week. Sudden withdrawals by heavily dependent users who are in poor health are occasionally fatal if the addicts fail to eat a healthy, balanced diet.

Secondary withdrawal symptoms can occur for weeks and months thereafter. These include chronic depression, anxiety, insomnia, loss of appetite, periods of agitation, and a continued craving for the drug. In some cases, the severity of depression leads to death from suicide. Addicts experiencing withdrawal may walk across congested freeways, fall or jump from balconies, or drive their cars into concrete abutments. In spite of the struggle for addicts, opium withdrawal is considered within the medical profession to be much less dangerous and difficult than alcohol or nicotine withdrawal.

own endorphins because the organism can not actually control how much of the feel-good chemical hits the brain."²⁰

When the opium wears off, however, the reuptake process begins and the endorphin levels drop, causing the euphoria to disappear as fast as it appeared. The euphoria is replaced by depression and the user experiences irritability, fatigue, and an intense craving for more of the drug to escape the depression.

Different opium alkaloids bind with different neurotransmitters. Some bind in the respiratory center of the brain, causing breathing to slow. When opium addicts overdose, the overload of those opium alkaloids that bind with respiratory receptors causes breathing to come to a complete halt. Other opium alkaloids bind with an area of the brain that inhibits sensitivity to the impulse to cough, while still others bind with receptors in the brain's vomiting center, inducing excessive nausea and vomiting.

The discovery of the brain's neurotransmitters and their ability to bind with opium alkaloids was revolutionary. Regardless of the useful scientific information it yielded, it convinced a majority of Americans and their political and spiritual leaders that all opium-based drugs should be confiscated and destroyed. Although opium is illegal today, such an objective is still a difficult undertaking, because the international opium alliance that produces and distributes opium throughout the world is a massive multibillion-dollar enterprise that resists efforts to eliminate it.