Opium

by Martin Booth

  It was not long before case studies were being published about the collapse of morphine addicts’ health, far worse than anything engendered by opium. The symptoms were soon recognised: a haggard appearance and emaciation, loss of sexual ability or desire and, as with opium, constipation. Attempts to break habituation led to what were described as severe flu-like symptoms.

  Warnings about the power of hypodermically injected morphine started to be published. A British physician, Dr T. Clifford Allbutt, reported in 1870 a lack of caution against morphine by injection, observing there were too many doctors for whom ‘the syringe and phial are as constant companions as was the lancet to their fathers.’ He went on to comment:

  Injected morphia seemed so different to swallowed morphia, no one had any experience of ill effects from it, and we all had the daily experience of it as a means of peace and comfort, while pain on the other hand was certainly the forerunner of wretchedness and exhaustion. Gradually, however, the conviction began to force itself upon my notice, that injections of morphia, though free from the ordinary evils of opium-eating, might, nevertheless, create the same artificial want and gain credit for assuaging a restlessness and depression of which it was itself the cause … If this be so, we are incurring a grave risk in bidding people to inject whenever they need it, and in telling them that the morphia can have no ill effects upon them so long as it brings with it tranquillity and wellbeing.

  The leisure use of morphine was well established by the time Allbutt published his paper. It was so widespread, writers of popular penny novels were using it as an image for dissolution. Allbutt commented on this, remarking: ‘Now that the hypodermic use of morphia is brought into sensational novels as a melodramatic device it may indeed be said to have reached the height of fashion. We may thank our stars if one of us be not seen ere long, syringe in hand, between Aspasia and Clodius in the windows of the Burlington Arcade.’ That was not all: morphinism soon became a metaphor as well as a novelist’s dramatic tool. In 1886, Lord Randolph Churchill compared Gladstone’s rhetoric on Home Rule to ‘the taking of morphia! The sensations are transcendent; but the recovery is bitter beyond experience.’ In actual fact, Churchill’s attack was close to the bone for Gladstone took laudanum in his coffee, apparently to increase his rhetorical powers when addressing Parliament.

  The first major contribution to the study of morphine was written by a German Jewish doctor, Edward Levinstein. His Die Morphiumsucht – published in English in 1878 as The Morbid Craving for Morphia – was divided into chapters on the symptomatology, etiology, prognosis and prophylaxis of morphine. It was not just a warning about the effects of morphine: it described a brand-new disease and suggested somatic origins for it. Whilst known to the medical fraternity, Levinstein’s book had scant initial impact.

  In 1882, The Lancet recorded that hypodermic injection was becoming general practice. The rapid increase in published case studies suggested an epidemic of addiction was imminent but the position was not quite so simple. Morphine use was popular and widespread but no more so than other opiates: indeed, compared to the prevalence of opium addiction in the working classes with which most doctors had little connection and which was beyond medical control, it was of far less concern. The truth was the medical profession singled out the injecting of morphine, which took on the aspects of an urgent problem, as becoming a cause for anxiety because they knew about it and it could be addressed.

  Dr Norman Kerr established the Society for Promoting Legislation for the Control and Cure of Habitual Drunkards in 1876: nine years later it was renamed the Society for the Study of Inebriety. Its primary aim was to reduce alcoholism – especially when it was caused by gin – which was rampant in the working classes but it included in its brief ‘narcotising agents’. Kerr believed opium addiction was less dangerous than alcoholism – although harder to cure – and he acknowledged the syringe was the most effective way of becoming inebriated. Within the medical fraternity, the society promoted the concept that inebriety from drink or drugs was a disease and the responsibility of medical men. Many doctors disagreed, regarding morphine or opium addiction (referred to as ‘narcomania’) as just a percentile of general inebriety. Drug addiction was actually called ‘drug inebriety’.

  Despite warnings about the unrestrained use of the syringe, so effective was the morphine injection, so quick was it to kill pain and so prevalent was the medical attitude towards treating symptoms rather than causes, the practice continued to grow and most standard textbooks made no reference to the risks. Not until around 1900 was drug addiction even referred to and it was not until 1910 that the dangers were fully comprehended, drug addiction becoming a separate medical issue. During the first decade of the twentieth century, the term ‘addiction’ was rarely used: in addition to drug inebriety, narcomania, morphinomania, morphinism, the morphine habit or opium-eating were the bon mots.

  By 1914 and the outbreak of war, addiction was recognised and named. What was more, there were now means to reduce it for other drugs had been invented which killed pain with far less risk. Acetylsalicylic acid, trade-named aspirin, appeared on the market in 1899 and, being cheap to produce, quickly took the place of laudanum or morphine in the treatment of lesser aches and pains. Several years later diethyl-malonyl-urea, an hypnotic drug trade-named veronal, came into wide use: although a dangerous substance, it was safer than opiates, especially when used as a sedative.

  However, no sooner was a knowledge of opium and morphine well disseminated than a newer, even more dangerously addictive drug appeared, deriving from but not a naturally occurring alkaloid of opium.

  The year 1874 was in retrospect a black day for both medicine and society. At St Mary’s Hospital, Paddington, in London, a pharmacist called C.R. Alder Wright was searching for a powerful, non-addictive alternative to morphine. He boiled morphine with acetic anhydride and created a substance which, believing morphine to be a double molecule, he named tetra-ethyl morphine. F.M. Pierce at Owens College experimented with this new substance, inducing sleepiness in dogs, dilating their pupils, causing them to salivate and vomit. In 1887, several papers were published identifying the now-named diacetylmorphine – the chemical formula for which was known to be C17H17NO(C2H3O2)2 – as a narcotic more potent than ethylated or methylated morphine: its single molecular structure was proven in 1890.

  Little work was done on diacetylmorphine until 1898, when a German chemist, Heinrich Dreser, working at the Bayer Laboratories at Elberfeld – where aspirin was also developed – produced a quantity of diacetylmorphine. After brief clinical tests, it proved to be an awe-inspiringly powerful painkiller. Bayer mass- marketed it under a brand-name Dreser had come up with based upon the German word heroisch, meaning mighty or heroic. It was called heroin.

  Whether made in a pharmaceutical facility or a clandestine laboratory, heroin manufacture is comparatively easy. Morphine is first extracted from raw opium by dissolving it in hot water and adding lime, which causes the precipitation of organic waste material, leaving the morphine in suspension as a white band near the surface. This is drawn off, reheated and has concentrated ammonia added to it. The morphine solidifies and sinks, to be collected by filtration. This is now morphine base. Ready for turning into heroin, it weighs about 10 per cent of the original quantity of raw opium: from 10 kilograms of raw opium comes 1 kilogram of morphine base which, with additional ingredients gained during processing, in turn yields slightly more than 1 kilogram of heroin.

  Heroin manufacture involves several processes. First, equal quantities of morphine and acetic anhydride are heated in a glass or enamel-lined container for six hours at 85°C. The morphine and the acid combine to form impure diacetylmorphine. Second, water and chloroform are added to the solution to precipitate impurities. The solution is drained and sodium carbonate added to make the heroin solidify and sink. Third, the heroin is filtered out of the sodium carbonate solution with activated charcoal and purified with alcohol. This solution is gently heated to evaporate
the alcohol and leave heroin, which may be purified further or converted to heroin hydrochloride, a water-soluble heroin salt.

  Heroin, which was distributed in small boxes with a lion and a globe printed on the label, was hailed as the new wonder drug, although more as a specific than morphine which had been applied to a wide range of ailments. Its effects were much faster for heroin rapidly turns into morphine on entering the bloodstream, so the effect is that of morphine except heroin is more soluble in fats and can therefore get into the central nervous system more quickly. Although it had analgesic potential and was five to eight times as powerful as morphine, it was promoted primarily as a non-addictive treatment for respiratory illnesses and the suppression of coughs. It was stated to be non-addictive on the contention that, although it was derived from morphine, the molecular structure had been altered by the manufacturing process, thus losing the addictive agent. It could be produced cheaply and relatively simply with a high degree of purity and quality control. Only small amounts were required per dose and it could be given by hypodermic injection although it was usually administered orally as pastilles – heroin cough lozenges were popular – or tablets, or as an elixir in glycerine solution. Within two years, it was widely used across Europe and the USA.

  History repeated itself. No sooner was heroin freely available than extravagant claims were made for it. It was even mooted as a cure for morphine addiction. Warnings soon began to appear, too: reports of tolerance and addiction were published in 1900, to be followed by others advising against heroin treatment for morphine addiction. The Council of Pharmacy and Chemistry of the American Medical Association included heroin in their annual publication, New and Non-Official Remedies published in 1906, but added the proviso, ‘The habit is readily formed and leads to the most deplorable results.’

  By 1910, the medical profession was fully alert to the danger of heroin and its medical use began to decline. However, factors came into play which led to the pan-global epidemic of heroin addiction which has increasingly plagued modern society.

  First was heroin’s effects. Its potential as a substitute for morphine, as well as being a more stimulating narcotic ‘leisure’ drug, became common knowledge. Second, it was introduced to society at a time when drug controls, especially in the USA, were just coming into force, thus restricting its availability: in the USA, it was used as an illicit pleasure drug by young criminals in the underworld of larger cities. Being cheaper than morphine, heroin was an ideal illegal commodity: as a white powder, it was also easily ‘cut’ or adulterated. In its pure form it was highly concentrated and therefore compact and easily concealed by traffickers. Inevitably, illicit heroin use grew rapidly and became the primary trade drug of the criminal underworld. Indeed, it was the criminal fraternity who originated the international heroin problem and not the medical profession who did not make addiction as widespread as they had done with opium and morphine.

  Over the space of the nineteenth century, opium had evolved from being a comparatively crude natural drug to providing not only the most effective painkiller yet known but also the most terrible and arguably most addictive drug. This, in turn, was to become an agent for one of the most insidious underminings of human society ever devised.

  6

  God’s Own Medicine

  Writing at the end of the nineteenth century, Sir William Osier called opium ‘God’s Own Medicine’ because it was a naturally occurring substance which could perform miracles and be used straight from the poppy, its active ingredients, like those of most plant-derived medicines, being its alkaloids which may be classed in two main groups. One, the pyridine–phenanthrene group, contains morphine and codeine, whilst the other, the isoquinoline group, includes papaverine and noscapine.

  As well as the main alkaloid constituents of morphine, noscapine, papaverine, codeine and thebaine, trace alkaloids include narceine, meconidine, codamine, laudanine, laudanosine, lanthopine, protopine, cryptopine, rhoeadine, oxynarcotine, pseudo-morphine, gnoscopine, xanthaline, tritopine and hydrocotarnine. In all, they account for only 20 per cent of opium by weight. The morphine content of opium is not standard and can range between 4 and 21 per cent according to country of origin with noscapine being the next most plentiful at 4–8 per cent.

  Today, only a very small quantity of opium is used medicinally, for example as an analgesic for patients suffering from cancer of the stomach, its main medicinal use being obtained from its alkaloids and derivatives. Morphine kills pain and euphorically relaxes the patient, although the majority of morphine is nowadays converted into codeine because the natural supply of that alkaloid is minute. Codeine is a less powerful analgesic and not as likely to cause addiction. Its usage includes the treatment of minor aches, pains and coughs. For years, it was available over druggists’ counters as an alternative to aspirin, but is now strictly controlled although it is still available. Noscapine is used to counteract coughing and papaverine has dramatic effects on increasing blood flow. Thebaine is a dangerous poison, causing severe convulsions, but its importance is that it can be converted into codeine and chemically altered to form other drugs. Heroin is a strong pain suppressive but it is not widely used in medicine outside Britain.

  Opiate is the generic term given to the group of drugs derived from natural opium or an alkaloid of it whilst semi-synthetic opiates are those produced by starting with a natural alkaloid then chemically modifying it: heroin may be classed as a semi-synthetic. Although synthesised, there are parts of the semi-synthetics’ chemical construction which mirror or echo that of their base alkaloid. Synthetic opiates – sometimes confusingly referred to as opioids – are drugs which act in the same way as natural opiates and semi-synthetics but they are entirely man-made: their chemical structure bears little or no relation to opium alkaloids. These include pethidine, often used to relieve pain in childbirth, dextropropoxyphene and methadone.

  Morphine, codeine and thebaine can all be used as the basis for a variety of semi-synthetic opiates which have become increasingly important in recent decades. Some are incredibly powerful. In the 1960s, a team working on thebaine under the prominent natural products chemist, Professor Bentley, in the Edinburgh laboratories of Macfarlan Smith & Co., made a literally unconscious discovery when someone accidentally stirred cups of mid-morning tea with a contaminated glass rod: within minutes several of the scientists were lying flat out on the floor. The company physician, Dr Simpson, was called. He monitored the comatose scientists, noting their heart rates, breathing patterns and behaviour before they revived. The drug they had unwittingly drunk was later developed into etorphine. Approximately 10,000 times as powerful as morphine, it is also known as M99 or Immobilon, and is used in dart guns to capture elephants and rhinos. Less than 2 millilitres will knock a full-grown white rhino senseless: a mere scratch from a contaminated needle can kill a man. Fortunately, there is an antidote called M50/50 or Revivon.

  The problem with opiates in general is that they are addictive and although the risk of dependence varies greatly from one to another, a frequent user will become habituated.

  Addiction is the compulsive taking of drugs which have such a hold over the addict he or she cannot stop using them without suffering severe symptoms and even death. Opiates are not unique. Cocaine, alcohol, caffeine and nicotine are also addictive, but they are nothing like as powerful as opiates in their hold over their victims. Nowadays, the term addiction is replaced by that of physical dependence, which is a more accurate definition, for addicts are frequently physically dependent upon their drug: this is certainly the case with opiates.

  The idea of dependence was defined in 1964 by the World Health Organisation as ‘a state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterised by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence.’ It is today consid
ered an illness.

  Opiate dependence is not a habit, nor is it a simple drive for some emotional craving. It is as fundamental to an addict’s existence as food and water, a physio-chemical fact: an addict’s body is chemically reliant upon its drug for opiates actually alter the body’s chemistry so it cannot function properly without being periodically primed. A hunger for the drug forms when the quantity in the bloodstream falls below a certain level, the addict becoming anxious and irritable. Fail to feed the body and it deteriorates and may die from drug starvation.

  This chemical relationship is easily proven. Not only humans can be addicted: so can other mammals. In Laos, where opium is commonly smoked, domestic pets such as cats and dogs become addicts by passively smoking their master’s pipes. Tame macaques in India may also become passive addicts and, in the past, became addicted by licking out cold opium pipes. Today, drug-sniffing dogs employed by customs authorities are sometimes trained on synthetic opium-smelling substances because they are liable to addiction. Addicts give birth to on average smaller babies which, after the umbilical cord is severed, may exhibit symptoms of opium withdrawal having been literally cut off from a supply they have known since conception.

  For the non-addict, one of the greatest mysteries is why someone takes to drug use knowing the terrible dangers. Philip K. Dick, the American science-fiction author, spoke for many people when he wrote in 1977: ‘Drug misuse is not a disease, it is a decision, like the decision to step out in front of a moving car. You would call that not a disease but an error of judgement.’ Clearly peer pressure, poverty and other social factors are likely to play their part in this decision-making process but the fact remains – why ‘hard’, very addictive drugs, such as opiates, instead of alcohol or ‘soft’ drugs such as marijuana? It may be that some, especially the very young, are unaware of what they are taking: this might account for the present-day world-wide trend towards younger and younger addicts. A young British addict who first took heroin at thirteen, not realising it was addictive, recently stated, ‘I was feeling left out. My mates were having a better laugh, so I tried it.’ A recent British survey has found Ecstasy users smoking ‘skag’ to ease the fading effects of an Ecstasy dose, in ignorance of what it is: skag is a street name for heroin.