1. A History of Drug Abuse and Addiction in the U.S. Sue Rusche, Co-director Addiction Studies Program

2. History of addictive drugs in the U.S. Marked by a recurring pattern –Widespread use –Problems develop –Reform/Laws

4. Opiates Widespread use in 19 th century –Primarily middle-, upper-middle-income women, Civil War soldiers Problems develop –Highest levels of opiate addiction in history Reform/Laws –Passed in states –Lead to Harrison Narcotics Act of 1914

6. Alcohol: Cycle 1 Widespread use 19 th, early 20 th century –Primarily men, all income levels Problems develop –Addiction –Breakup of families, other social problems Reform/laws –Passed in states –Lead to Prohibition

7. Alcohol: Cycle 2 Widespread use –Prohibition repealed 1933 –Use highest by 1980 after period when states lowered drinking age to 18 Problems develop –Highest ever rates of drunk-driving deaths, especially among adolescents –100,000 deaths per year Reform/laws –States raise drinking-age to 21 –Pass anti-drunk driving laws

9. Cigarettes/Tobacco Widespread use –0 cigarettes per person/1860 –4,345 cigarettes per person/1963 Problems develop –Up to 500,000 deaths per year Reform/laws –Local anti-smoking laws in public places –State lawsuits result in Tobacco Settlement Act

11. Medicines: Cycle 1 Widespread use –Little understanding of disease –Only medicines were potions, elixirs Problems develop –Most medicines either worthless or harmful Reform/laws –Public concern leads to Pure Food & Drug Act 1906

13. Medicines: Cycle 2 Widespread use –Dietary Supplement Health and Education Act of 1994 –Dietary supplements exempt from FDA control Problems develop –i.e. Ephedrine Reform/laws –Under consideration

14. Impossible to talk about medicines without talking about addictive drugs Addictive drugs have been used as medicines throughout history –Opium and heroin –Cocaine –Cannabis –Alcohol

15. Put in perspective... Anesthetics not developed until 1840s Modern pharmaceuticals, medical procedures developed even later

16. Pre-1840s “anesthetics” Got patients very drunk Knocked them out with blows to the head Hired several large men to hold them down

17. Advances in chemistry, technology: Morphine isolated from opium (early 1800s) Cocaine extracted from coca leaf (mid- 1800s) Hypodermic needle invented (mid-1800s)

18. Opiate addiction spread in last half of 19 th century via: Medical administration Doctors gave morphine to relieve symptoms, treat gynecological problems and “nervousness” in women who could afford doctors Civil War Doctors gave morphine to treat Civil War injuries Self-administration via patent medicines

24. Opiate addiction spread, cont. Medical use to “cure” addiction Denarco, Opacura Non-medical administration Opium smoking, eating

26. U.S. importation of crude opium quadrupled in last half of 19 th century

27. Patent medicines also contained other addictive drugs

32. Absence of regulation No labeling requirements People unaware of what they were taking Addiction spread

33. No requirements for safety, efficacy Anyone could produce, sell “medicines” –Unsafe –Ineffective –Made curative claims without benefit of scientific proof

39. By early 1900s, medical consensus developed: Opiates, other drugs overly prescribed Sold to unsuspecting customers & produced addiction Worthless patent “medicines” being sold Controls needed

40. Public pressure for controls mounts States pass laws to –Control opiates, cocaine, other addictive drugs –End sale of worthless “medicines”

41. Federal Pure Food and Drug Act of 1906 (& subsequent amendments) Food, drugs pure Contents labeled Drugs must be safe and effective Food and Drug Administration

42. Harrison Act of 1914 (& subsequent laws) First law to control opiates, cocaine, other drugs Subsequent laws attempt to balance –Use in medicine with potential for abuse Marijuana Tax Act of 1937 –Adds cannabis

43. High levels of alcohol use, problems in 1800s Similar effort to control alcohol –States passed prohibition laws –1851-1865

44. US Internal Revenue Act of 1862 Taxed alcohol to raise money for Civil War –Raised up to half of U.S. internal revenue between 1870 and 1915

45. Volstead Act (1919) Codified 18 th Amendment to U.S. Constitution (Prohibition) Results: –Lowest levels of alcohol consumption –Lowest levels of cirrhosis deaths

46. Support diminished as Illegal supplies increased Wood alcohol poisoning deaths increased Business leaders believed alcohol tax would replace personal, corporate income tax U.S. repeals Prohibition in 1933

47. Nicotine: addictive drug that escaped control until today Tourists introduced cigarettes from Europe in 1850s Once introduced, use spread

48. Government taxed cigarettes To raise money for Civil War Mass production & mass marketing led to enormous growth in production and sales

49. # Cigarettes produced (in thousands)

50. First scientific study linked cigarettes, lung cancer -- 1937 By 1960s, conclusive evidence that smoking causes –Lung cancer –Heart disease –Emphysema –Many other cancers

53. After passage of FDA laws, drug control laws Nation settled into a long period of relatively little drug use Illicit drug use in 1962: –Less than 2 percent all ages –Less than 1 percent adolescents

54. 1960s social protests, Vietnam War Drug use rose to highest levels ever. By 1979: –25 million Americans used drugs regularly –One-third of adolescents, 70 percent of young adults, 65 percent of high school seniors had tried an illicit drug

55. Past month drug use, 2004 (in millions)

56. Drug deaths per year

57. Past-month drug use, high school seniors

58. America’s 8 th Grade Students 22%

59. America’s 8 th Grade Students 28%

60. America’s 8 th Grade Students 44%

61. America’s 12 th Grade Students 51%

62. America’s 12 th Grade Students 53%

63. America’s 12 th Grade Students 77%

64. Cost of substance abuse Of all preventable health problems, substance abuse causes: –More deaths –More illnesses –More disabilities

65. Economic cost of alcohol $166.5 billion

66. Economic cost of smoking $138 billion

67. Economic cost of drug abuse $109.9 billion

68. Rising drug use in 60s, 70s & development of new technologies Spurred scientific investigation of drug abuse and addiction

69. Discovery of endogenous opioids in the brain (early 1970s) Explosion of scientific knowledge –How the brain works –How drugs act on the brain Led to understanding –How people become addicted –Why it is so hard to recover

70. Drug abuse, addiction Result from a combination of factors –Behavioral/biological –Genetic –Social/environmental

71. This new knowledge is the subject of our workshop for the next two days. (Continue)

72. For more information: 1. An explanation of the Food and Drug Administration’s New Drug Approval Process http://www.fda.gov/fdac/features/2002/402_drug.html

74. For more information: 2. History of the Food and Drug Administration http://www.fda.gov/oc/history/default.htm http://www.cfsan.fda.gov/~lrd/history2.html

77. For more information: 3. U.S. Controlled Substances Act http://www.dea.gov/pubs/csa.html http://www.dea.gov/pubs/scheduling.html

80. Bibliography Austin, Gregory. Perspectives on the History of Psychoactive Substance Abuse: Research Issues 24. 1978, National Institute on Drug Abuse, Rockville, Maryland. Musto, David. The American Disease: Origins of Narcotic Control. 1999, Oxford University Press, Oxford, England. Friedman, David and Rusche, Sue. False Messengers: How Addictive Drugs Change the Brain. 1999, Harwood Academic Publishers, Amsterdam, The Netherlands. Brandeis University. Substance Abuse: The Nation’s Number One Health Problem. 2001, The Robert Wood Johnson Foundation, Princeton, New Jersey. Courtwright, David T. Dark Paradise: A History of Opiate Addiction in America. 2001, Harvard University Press, Cambridge, Massachusetts.