How can opium be so ancient, and addiction so modern? The drug has not changed, nor has the human metabolism. In the earliest written records – Sumerian tablets and Egyptian papyri – it is already praised as a euphoric, a sedative and a supreme remedy against pain. Galen and his contemporaries added cautions about its dangers, but the most emphatic of these concerned overdose: the difference between an effective dose and a lethal one is uncomfortably small, and the tolerance that develops rapidly with regular use means that no standard dose can be stipulated. Compared to this urgent caveat, the need to increase dosage over time was little more than a footnote: for most classical authorities it merited less attention than the other universal side-effect of regular use, constipation.
Early Arab sources are the first to foreshadow the modern phenomenon of the addict. A 12th-century doctor noted that some visitors to Mecca were ‘dangerously obsessed with their craving’, and resorted to crime to gratify it; Avicenna warned sagely: ‘Collect your fee before you dose your patient with the poppy.’ But while compassionate doctors such as Maimonides prescribed opium freely for chronic pain (‘the dying must not be left to suffer’), in Europe it would be centuries before this became part of medicine’s remit. In Thomas Dormandy’s sobering litany, St Teresa of Avila, Philip II of Spain, Charles II and Louis XIV were among millions who died in protracted and unnecessary agony: ‘All were surrounded by the best medical talent of their day. None was offered opium to ease their suffering.’
It was the 19th-century revolution in attitudes to pain that prompted opium’s emergence as a problem drug, and addiction as the medical condition that underlay it. The Romantic sensibilities that turned public opinion against slavery, cruelty to animals and public hanging also transformed the relief of suffering from a luxury into a necessity. The spread of tuberculosis, in particular among the young, presented a stark choice between years of constant torment or blessed relief through opium, with dependence as a small additional cost. Despite resistance from some medical and religious authorities who maintained that pain was a physical or spiritual necessity, the use of opium to relieve it came to seem no more than common kindness.
The new demand was more than matched by supply. With the decline of Venice, Turkish opium flooded into Marseille and Amsterdam and was auctioned by the candle in the City of London. As production was stepped up and prices dropped, patent medicines were loaded with sweet syrups to conceal the bitterness of the one remedy which, whatever the customer’s ailment, was guaranteed to make them feel better. Opium was often cheaper than alcohol, and the line between medicine and recreation was blurred. In some areas – in Britain most notoriously the ‘poppyland’ of the East Anglian fens – shopkeepers on market days would line up tots of laudanum tincture on their counters for visiting farmers to drink on the spot, with half-pint bottles and jars of opium pills to see them through the week.
New forms of consumption also tilted perceptions of opium from medical remedy to means of pleasure. In China, where opium had been introduced as an additive to Dutch tobacco, a new pipe design was introduced that enabled pure opium to be efficiently vaporised and inhaled. As well as providing a more rapid and intense high, Chinese opium-smoking transformed the drug from a medication consumed in private to a convivial shared intoxicant. De Quincey, by calling himself an ‘opium-eater’ (although, like most people in Britain, he drank it), mischievously cast himself as a decadent infidel; but the opium pipe, which was being adopted in China just as De Quincey’s Confessions became a literary sensation in Europe, provided an even more strikingly alien and sinister image. Although its botanical and medical origins are firmly European, from this point on opium would be recast in European minds as a drug of the Orient, with all its capacity for pleasure, cruelty and sensual wickedness. It was, however, European and particularly British traders that opened up and profited from new Asian markets: mass production by the East India Company in the poppy fields of Bengal combined with aggressive smuggling into China by free traders such as Jardine and Matheson, who flew a St Andrew’s cross as their ensign and enlisted missionaries to distribute opium along with translations of the scriptures, a ‘wholesome coupling of bodily wellbeing and spiritual uplift’.
But the spur to the modern diagnosis of addiction was the combination of a novel compound, morphine, with a novel delivery system, the hypodermic syringe. Together, these offered a revolution in the human condition: relief from pain that was almost instant and almost total. By 1860, the needle and vial were transforming palliative care and surgical recovery, but the vector for their widespread adoption was war: in particular the American Civil War, which claimed 620,000 fatalities and created fifty thousand amputees, and during which more than ten million doses of morphine were consumed. Over the following decade, doctors promoted it enthusiastically as a ‘pure’ alternative to opium preparations of dubious quality, and injection as the preferred method for delivering rapid relief and a clinically accurate dosage.
Initially, patients were taught to inject themselves: the high-minded author Mrs Humphry Ward insisted that ‘my syringe and needle, like my toothbrush and prayer-book, are sacrosanct. I would not dream of allowing even my best friend to use them.’ But it soon became obvious that some patients were finding the morphine shot far too good to confine to medical emergencies, and that the dangers of abuse were far greater than they were with opium: its wonderful potency and immediacy increased the incidence both of overdose and of compulsive and excessive use. The expanding taxonomy of mental illness attempted to distinguish ‘morphinists’ (addicted through medical treatment), ‘morphinomaniacs’ (who took it without medical supervision and refused to stop) and ‘narcomaniacs’ (those with a prior mental imbalance who became fixated on it).
The medical basis of addiction was always problematic, however. Was it a disease in its own right, or a symptom of another condition? Was it a function of the drug, or of the subject’s nervous constitution? Narcotics were promoted as therapy for the new nervous disorders, but those suffering from nervous disorders were also the most likely to succumb to addiction. Most troubling, the most common victims in the first wave of addiction seemed to be doctors themselves. In 1885, the American physician J.B. Mattison claimed that a third of all doctors in New York were morphine addicts; a survey by the Berlin pharmacist Louis Lewin reported that doctors, dentists, surgeons and their wives made up the majority of cases. If medical professionals were so readily enslaved, what hope for the general public? For all its miraculous powers, some physicians questioned whether the use of the drug was compatible with the Hippocratic oath, or whether, as George Bernard Shaw charged, it was turning them into ‘licensed murderers’.
It was in the United States, where addiction was seen as peculiarly un-American – resulting in ‘a life of weakness, decadence and, above all, social uselessness’ – that the movement to ban all non-medical use of opiates began. Like most such prohibitions, it was in reality a substitution: new sedatives and painkillers, from aspirin to barbiturates, masked the disappearance of the age-old remedy from the pharmacy shelves. In Britain, the first laws were passed during the Great War, prompted by concerns over abuse in the armed forces: one of the first prosecutions, in 1916, was of Harrods for selling gift-wrapped packets of morphine as ‘useful and attractive presents for friends at the front’. But war continued to be a powerful recruiting sergeant: as Hans Fallada observed of the Second World War, ‘morphine was the only ministering angel who, without ideology or war aims, served mankind impartially in its madness.’
‘Is it a sin, a crime, a vice or a disease?’ asked the Society for the Study and Cure of Inebriety in 1884. The 20th-century prohibitions on opiates failed to resolve the question. In the US, the Harrison Narcotics Act of 1914 insisted that addiction was not a disease but a ‘self-inflicted moral infirmity’, which meant that American doctors who prescribed to addicts were liable for criminal prosecution. In Britain, the resolutely non-penal Rolleston system treated it as a disease requiring medical care. Neither country succeeded in confining opiates to their newly legislated use. The illicit market coalesced around heroin, a stronger form of morphine that until 1913 had been a bestselling over-the-counter cough suppressant but from 1946 was reliably supplied by Lucky Luciano’s crime syndicate. Once supply and demand were in place and a vast profit margin established, the policy of criminal enforcement was doomed. In 1971, Nixon famously declared a ‘war on drugs’ (Dormandy reminds us that he also described it as ‘our second civil war’), and subsequent UN conventions have reaffirmed and extended the global anti-drug crusade; but the illicit drugs market now operates on a scale the original legislators could never have imagined.
Although the ‘disease model’ of addiction still underpins such therapeutic undertakings as Narcotics Anonymous, practitioners and policymakers increasingly use circumlocutions such as ‘problematic’ or ‘misuse’, which frame it as a behaviour rather than a literal illness. In other branches of medicine, the strict pathological view of addiction has been an impediment to progress: Dormandy writes powerfully, as he has elsewhere, of Cicely Saunders’s struggle to establish palliative care for the dying, from whom opiates were commonly withheld on the grounds that they are addictive. Recent revisions of the DSM-IV diagnostic criteria have eliminated the term, replacing it with ‘substance dependence’, defined pragmatically as a ‘maladaptive pattern of substance use leading to clinically significant impairment or distress’.
Soft-pedalled within medicine, the idea of addiction has run rampant in the wider culture, where drugs are losing their monopoly on the diagnosis to shopping, gambling, sex, eating and other manifestations of individual choice and consumption run out of control. Addiction is now the language in which older discourses of temptation, indulgence, temperance and redemption are conducted. The panoramic view of opium’s history shows clearly enough that it has always had its dark aspect, but suggests that in the modern era we have also become addicted to what Walter Benjamin called ‘that most terrible drug – ourselves – which we take in solitude’.