How the Opioid Epidemic Became a Uniquely American Problem

In recent years, the opioid crisis and the toll it has taken on American families has dominated headlines. Now that nearly 400,000 American lives have been lost, there’s been much debate over who the true culprits behind the epidemic are, from Big Pharma to doctors to billlionaire families like the Sacklers, which are now facing more than 1,000 lawsuits accusing them of deliberately downplaying the risks of prescription opioids in order to continue reaping profits.

But as Rund Abdelfatah and Ramtin Arablouei, the hosts of the NPR podcast Throughline, recently found while researching their episode on the history of opioids in the United States, the roots of the crisis go back much further than one would suspect. The story of the opioid crisis, Adelfatah says, is essentially a story of pain, and how Americans have historically treated it: “There was a recurring question of whose pain is taken as ‘real pain’ and how do we address it?,” she told Rolling Stone. “There was definitely a gender bias in the 19th Century around treating pain; there was a racial bias, and a lot of these biases remain in different forms today.”

As Throughline recounts, the roots of the opioid crisis go as far back as the mid-19th Century, when German pharmacist Friedrich Sertürner discovered morphine while conducting experiments with the opium poppy plant. Despite Sertürner’s concerns that morphine was addictive, and should thus be used sparingly as a method of pain relief, doctors started prescribing it for soldiers who had been injured on the Civil War battlefield. “When the war ended, not only do you have a lot of soldiers addicted, but you have this new drug introduced into American life,” Abdelfatah says. The drug started being prescribed primarily to white women in the United States, for ailments ranging from coughs to menstrual cramps, primarily because physicians thought women were less able to tolerate pain.

As patients started dying of overdoses, physicians started to realize just how addictive and dangerous morphine was, which prompted them to start prescribing what they then considered a less addictive substitute: heroin. Companies like Bayer advertised heroin as a safe medical treatment for respiratory ailments — even marketing it to children. One Spanish-language ad dated from the turn of the century shows a mother giving it to her daughter by the spoonful. “It’s fascinating how in-your face it is, and it shows the evolving attitude we and the advertising community have had toward opiates in our culture,” Arablouei says. 

The possession and manufacturing of heroin was criminalized in 1924, driving the sale of the drug underground. This, in turn, led to people in urban, black or brown communities becoming addicted to the drug, prompting a cultural shift from treating opiate addiction as a medical problem to a criminal one. “There tends to be a more aggressive response to drug epidemics — as in, more criminalization — when it happens in communities that are urban, black or brown. That tends to be the historical pattern,” Arablouei says. “You see that play out with heroin, when the problem plays out underground. And you can see that today: a lot of attention is paid to the opioid crisis, and there’s a lot more empathy from politicians than you saw from them toward, say, the heroin epidemic [in urban communities], or the crack epidemic in the Nineties.”

The advent of Oxycontin in 1996, combined with doctors’ endorsements of the drug as a method of non-addictive and long-lasting pain relief, prompted the birth of the prescription opioid epidemic as we conceive of it today. Companies like Purdue Pharmaceuticals, run by the billionaire Sackler family, perfected the art of using medical professionals’ endorsements to market opioids to patients suffering from chronic pain — and the result, as we now know, has been an epidemic of massive proportions, which has resulted in the loss of hundreds of thousands of lives.

Over the course of the past few centuries, opioid addiction has been treated both as a medical problem and a criminal one, depending on the communities it has touched. While today it’s viewed primarily as a white, middle-class, rural phenomenon, that’s changing rapidly as drugs like fentanyl are increasingly being distributed in urban communities. “It might have started out as a majority white community problem, but it no longer is that,” says Adelfatah. “It affects almost every community, almost every race and demographic in the country.”

Throughout the history of the epidemic in its various forms, however, what hasn’t changed is its uniquely American nature, as Arablouei describes it. “Our culture has gotten so good at marketing and that marriage of capitalism and marketing and medicine has been perfected here in America, for good or bad,” he says. “[And] that has made it a very American crisis.”

You can listen to the Throughline episode below.