The United States has made various social and legislative attempts to deal with addiction, especially in the twentieth century. But history reflects our society’s ambivalence about whether to outlaw addictive substances or to allow and regulate the consumption of them. Efforts to ban the use and sale of alcohol during Prohibition led to the growth of an underground black market and organized crime. When it was believed that heroin addiction was the cause of increasing inner-city crime in the 1940s and 1950s, heroin addicts were listed on federal registers and sent to federal treatment centers. The advent of methadone maintenance treatment, controversial as it was, allowed heroin addicts to reenter society but made little impact on the course of the addiction itself in the individual addict.

In the 1960s the use of hallucinogens for their “mind expanding” powers was promoted by some, and legislation was passed to decriminalize the possession and use of marijuana.

The subsequent epidemic of crack cocaine use, however, increased public concern about the destructive aspects of drug addiction, and vast amounts of tax dollars have been spent on the “war on drugs.” When AIDS became epidemic among intravenous drug users, proponents of clean needle programs came forward, but so did people who strongly opposed those programs. We have seen increasing social concern about drunk driving, but attempts to lower the legal alcohol blood limit nationally have engendered controversy.

And while some debate the regulation of nicotine products, including cigarettes, others promote the easing of restrictions on casino gambling.

Before the early 1900s, unregulated sale of patent medicines led to widespread opiate addiction. In the 1800s most pharmacies sold preparations such as Dover’s Powder and McMunn’s Elixir of Opium, which contained morphine. Derivatives of the coca plant including extracts and pure cocaine were widely used for their stimulant properties and were not considered harmful. Coca-Cola is an example of a popular tonic that contained active cocaine when it was first produced.

Some acknowledgment of the addicting nature of these patent medicines was made in the medical and religious literature, but social disapproval of their use was minimal.

In the early 1900s the federal government instituted control over the sale and use of opiates. The Pure Food and Drug Act of 1906 required that all patent medicines have an accurate list of ingredients, conform to standards of purity, and truthfully describe their intended effects. Public awareness of the extent of the availability of opiates increased, and educational efforts were made to reduce the prevalence of addiction to these tonics.

The Shanghai Opium Commission was convened under the leadership of Theodore Roosevelt and led to the adoption of the Smoking Opium Exclusion Act of 1909. The Hague Treaty of 1911 called for national and international efforts to curb the use and distribution of opium and coca products.

These actions stemmed from the conflict in the Far East over the opium trade and the international recognition of a need to control and monitor the production and distribution of narcotics, including the “tonics” that contained opiates.

The Harrison Narcotics Act of 1914 was a landmark in government regulation of addictive substances. It was followed by a series of revisions and further regulations that instituted and strengthened federal government control of the possession, distribution, and use of opiates and cocaine. The prohibition of alcohol began in 1919 following ratification of the Eighteenth Amendment by all but two states. Marijuana came under federal control following the Marihuana [sic] Tax Act of 1937.

At the present time, no fewer than twenty-two federal agencies play a role in the implementation of federal drug policy and participate in the Demand Reduction Working Group, which is charged with implementing aspects of the National [drug] Strategy that deals with the problem of addiction itself. The government also directs efforts at reducing the drug supply and at coordinating state and federal activities through the Office of National Drug Control Policy, which was created in the late 1980s.

The Drug Enforcement Administration (DEA) was established in 1973. It grew out of the Narcotics Division of the Treasury Department’s Internal Revenue Bureau, which was created in 1919 to enforce alcohol prohibition, and the Federal Bureau of Narcotics, which was established in 1930. This regulatory department merged with the law enforcement agency known as the Office of Drug Abuse Law Enforcement.

One function of the DEA is the scheduling, or regulation, of addictive substances and the licensing and oversight of the prescribing and dispensing of regulated substances. These substances include most of those known to cause problems with addiction, with the exception of alcohol. A drug is assigned to one of five groups called schedules. The lower the number, the more addictive or problematic the substance. For example, substances found under Schedule I, such as marijuana and heroin, are highly addictive and problematic and have no legal medical use. Substances found under Schedule V, such as paregoric and some cough preparations, have little potential for addiction if used properly.

A major loophole in the law involves substances that can cause addiction but are not scheduled. A drug cannot be scheduled if it is not known to exist, because drugs that are scheduled are specifically identified by their chemical structure. Clever chemists have taken advantage of this loophole by creating “designer drugs” - chemicals closely related to scheduled drugs but technically not illegal. Tragic consequences have resulted from reckless experimentation with these designer drugs. A small change in chemical structure can produce a toxin that mimics an illegal drug. An epidemic of severe Parkinson’s disease in young adults was attributed to the production and distribution of such a chemical. Parkinson’s disease is a degenerative brain disorder that results in tremors, stiffness, immobility, and loss of mental capacity. A particular designer drug caused permanent brain damage in its users, leaving them crippled and institutionalized.

As we learn more about what makes substances addictive and how to study them in the laboratory, more drugs come to be considered for scheduling. One of these is the compound ephedrine, which is currently available over the counter; it has a chemical structure resembling that of the amphetamines and produces similar effects. Cases of ephedrine abuse and dependence are not uncommon. Ephedrine is also used illegally by chemists to prepare illicit drugs. Another is the muscle relaxer Soma, which was not initially thought of as a drug with potential for abuse, but so many clinicians have seen patients who take advantage of its sedative properties that it has now been recognized as problematic.

Some synthetic drugs were initially marketed because the manufacturers believed that the new chemical structure would be less addicting than the natural compound from which they came. An example of this is pentazocine (Talwin), a potent painkiller that is used following surgery or with painful conditions such as cancer. It was initially thought to be less addictive than natural morphine, which it was meant to replace; however, it quickly joined the ranks of drugs being abused. In the late seventies and early eighties it was popular among drug abusers in the form of “T’s and blues,” a combination of Talwin and an antihistamine which were melted down and injected.

Some people are of the opinion that just about anything can be abused if it is used to excess, even aspirin or Tylenol.

But some drugs that we use for emotional conditions such as depression and psychosis don’t seem to have any abuse potential at all. One clever way of monitoring this is to study what the street value is of a drug once it is in general use.

Street value is the amount of money an addict will pay for a dose of the drug on the street. So far, all of the classes of drugs that are known to have street value interact in some fashion with the pleasure center of the brain. Drugs that don’t do this seem not to develop a street value or to have much potential for misuse or addiction. One study showed that there were some drugs street addicts would pay for and some they would pay not to take! The ones they didn’t like were drugs that are legitimately used for some psychiatric disorders. People don’t become addicted to most of the drugs that are prescribed for emotional and psychiatric conditions.

As a society, we continue to be ambivalent about how to deal with addiction. Cultural attitudes are important, as are legislation and regulation, but in the end the solution lies with individual choice. Attention to mental problems such as depression, anxiety, and psychological trauma, support from families and friends, and the expectation that each individual will assume personal responsibility for making choices are social factors that favor a reduction in the prevalence of addiction. As we develop more effective treatments and increase our awareness of addiction and its many manifestations, we can hope to see such a reduction. But we have a long, long way to go.

Elizabeth Connell Henderson, M.D.

Glossary

Appendix B: Sources of Additional Information