Two timeless and competing human desires have driven the story of opioids in the U.S.: a yearning to ease pain and a zeal to profit from it. 

The plot begins with the delicate poppy flower and the milky sap that oozes from its seed pods. It took millennia for opium to reach North America, where colonists eased ailments with laudanum, a bitter elixir of alcohol and opium. In the 19th century, recreational smokers sought opium for euphoria and relaxation, while parents soothed restless and teething babies with opiate-laced syrups. Women sipped opium tinctures for everything from menstrual cramps to anxiety.

But opium was notorious for its unpredictable potency. Seeking a more controlled medical formulation, a young German pharmacist's apprentice named Friedrich Wilhelm Adam Sertürner isolated one of opium’s active ingredients in the early 1800s. He named the new compound after Morpheus, the Greek god of dreams.

“Everything changed with the isolation of morphine from the poppy plant,” says Travis Rieder, PhD, associate research professor at the Berman Institute of Bioethics.

In the mid-19th century, another advance increased the likelihood of opiate addiction: hypodermic medication. Unlike pills, powders, and tinctures, injected morphine offered immediate pain relief. In the post-Civil War years, millions of Americans suffering from amputations, broken bones, and lingering illnesses such as tuberculosis and dysentery fueled the country’s appetite for morphine.

As the wave of addiction swelled, so did public anxiety—and disdain. In the 1870s, a flurry of articles in medical journals described the pitfalls of opiate overprescribing. Amid these competing fears and desires, a question emerged: Was a potent non-addictive painkiller possible?

“This sparks this pharmaceutical arms race: the search for the holy grail of pain medicine,” says Rieder.

In 1898, The Bayer Co. introduced its new remedy for cough and pain: heroin. Some believed it would prove less addictive than the morphine it was derived from, but reports of heroin addiction soon proved otherwise.

Reformers called for increased government regulation. The 1906 Pure Food and Drug Act required that drugs list active ingredients such as opiates. The 1914 Harrison Narcotic Act taxed and regulated the industry, requiring registration for anyone dealing in opiates, including doctors who prescribed it.

“All of this is designed to bring narcotics under control and limit distribution to medical channels,” explains David Courtwright, PhD, a historian, author, and expert in U.S. drug history.

While the Federal Bureau of Narcotics, formed in 1930, clamped down on diversion and dodgy prescribing, the illicit market for heroin expanded in big cities. By 1965—the end of an era that Courtwright calls the “classic age of narcotics control”—penalties were onerous and racial minorities were disproportionally impacted.

“It was a mess, and everyone recognizes it was a mess,” Courtwright says.

The Controlled Substances Act of 1970 tidied up by sorting selected psychoactive drugs into five classes based on accepted medical use, potential for addiction, and harmfulness. Once again, the country grappled with the competing desires to provide legitimate medications to patients while protecting the public from their dangers.

In the 1970s and 1980s, a handful of doctors began questioning conservative prescribing norms. Was the risk of addiction a reason to deny relief to millions of chronic pain patients? The critics seized on a one-paragraph 1980 letter to The New England Journal of Medicine that described how rare narcotics addiction was in hospitalized patients. It would be cited more than 600 times, usually without the “hospitalized patients” detail.

“It’s not so much that we forgot the lessons of history as that the industry turned them on their heads.” 

By the late 1990s, a campaign funded and orchestrated by the opioid industry had elevated pain to “the fifth vital sign” and laid the groundwork for the blockbuster success of Purdue Pharmaceutical’s OxyContin, launched in 1996. As marketing intensified and prescribing expanded, so did diversion and addiction.

Regional newspapers broke the story in 2000, followed over the next decade by national media stories of pill mills, overdoses, and grieving families. More than a century after the first addiction crisis, the U.S. had fallen into a familiar trap. Trying to ease chronic pain with novel forms of narcotics had provoked a sharp increase in addiction and related mortality.  

“It’s not so much that we forgot the lessons of history,” Courtwright says, “as that the industry turned them on their heads.”    

A perfect storm of relaxed regulations, deceptive marketing, pharmaceutical lobbying, and aggressive prescribing spread addiction and drove up overdose deaths. In 2007, Purdue and its top executives pleaded guilty to misleading the public about OxyContin’s risks and paid more than $600 million. In 2012, a Senate panel investigated the relationship between opioid manufacturers and pain advocacy groups.

“This helped the medical community figure out we’d been duped,” says Andrew Kolodny, MD, president of Physicians for Responsible Opioid Prescribing.

By 2016, the tide was turning in the medical community. Per capita consumption of prescribed opioids had been falling for five years. Yet the worst of the addiction and overdose epidemic was still to come.

In response to steadily tightening restrictions on prescriptions, many Americans turned to cheaper and more accessible street heroin. As demand grew, the street supply became tainted with the highly potent opioid fentanyl. In 2021, the country surpassed 100,000 overdose deaths, an unprecedented figure driven by synthetic and increasingly illicit opioids.

Today, public health interventions aim to stem the deaths by offering over-the-counter naloxone to reverse opioid overdoses and relaxing restrictions on buprenorphine, a treatment for opioid use disorder.

“I would like to think we’re in the abatement era,” says Epidemiology Professor Caleb Alexander, MD, MS. “Gradually, communities are increasingly aligning and investing resources to abate the epidemic and do so in a more systemic and coordinated fashion.”

As scholars analyze the country’s recent history, new themes will likely emerge, says Hopkins’ Jason Chernesky, PhD, a historian who is researching the opioid industry documents.

"There might be a new way historians can rethink these stories," Chernesky says. “What kinds of narratives should still be told?"