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I once carried out a general practice surgery where the first two patients requested opiates but for entirely different reasons. I was struck at the time by the difference in my response. The first patient was an elderly man with pancreatic cancer. He came for a repeat prescription for a concentrated morphine solution to control his metastatic pain. I gave it to him willingly, and told him he could take it as often as he needed. I reminded him that, when necessary, I would be very happy to organise a syringe driver for him at home, so he could receive a continuous infusion of diamorphine intravenously. The next patient, however, had an entirely different presentation. She was a young woman from outside the area who had asked to be seen urgently. She told me she was recovering from heroin addiction and was on a methadone programme to aid her withdrawal. She said her handbag was stolen the previous day, with her prescription in it. Would I please issue a replacement? I politely refused. I explained that, like most surgeries these days, we had a firm practice policy, restricting such prescriptions to patients who attend our substance misuse clinic. She left with little protest.
A visitor from another planet, observing these two consultations, might have been puzzled as to why I was so relaxed and generous with one person, and so strict with the other, when they were asking for similar drugs in almost identical doses. I would have had to explain that, sadly, consultations like the second are about 10 times as common as the first in inner city practices: the first patient's request was legitimate, while the second was almost certainly deceitful, and driven by a helpless craving for the drug itself.
For patients and doctors alike, opiates are a blessing and a curse, a source of angelic relief from suffering and a diabolical cause of it. Morphine and heroin draw their users into the same polarisation as the drugs themselves. We admire one group as moral heroes for taking these as they face the ultimate challenge of their lives. We approach the other group too often as moral failures—with suspicion at best, rejection at worst. No other class of drugs has such powerful physical and psychological effects. None has such a Manichean image in our society, culture or political debates.
It is tempting to believe that this is a relatively recent state of affairs, but it is not. A book called simply, Opium, by the chemical pathologist Tom Dormandy, examines these drugs from every conceivable angle.1 A pioneer of research into free radicals, and a polymath in his interests, Dormandy died recently at the age of 86. He had previously published books on tuberculosis and art history, and was an accomplished painter. In Opium, he displays a comfortable, almost affable familiarity with multiple languages and cultures, world history, politics and literature as well as pharmacology and therapeutics.
The opium poppy, Dormandy explains, is ancient and ubiquitous. Lake dwellers in Switzerland consumed its seeds in buns in the late Stone Age. In Egypt and Mesopotamia, physicians prescribed poppy juice along with prayers, incantations, amulets and religious rites. Homer described how Helen of Troy added it to wine to cheer up her guests. The Roman emperor Nero succeeded to the throne after his mother had used it to dispose of his rivals. During barbarian times, opium disappeared from Western Europe but reappeared in Baghdad. In 1130 AD the physician Abulrayan al-Biruni noted that some pilgrims to Mecca took fatal overdoses. He enumerated the 10 basic symptoms of overdose: ‘lethargy, lockjaw, uncontrollable itching, watering eyes, paralysis of the tongue, discoloured extremities and nails, profuse cold perspiration, painful but ineffective vomiting, convulsions and death’. As Dormandy notes, ‘little could be added to the list today’. In later centuries, opium cultivation moved between continents. Under the Ottoman Empire, the poppy fields in Turkey spread for hundreds of miles. In the 18th century, production moved to the Ganges valley, where the plantations were controlled by local potentates until the British colonists took them over. In the 20th century, cultivation was concentrated in the ‘Golden Triangle’ in northern Thailand, and later in Afghanistan.
Some of the facts about opium covered in the book are well known. It played a prominent part in the Romantic Movement, particularly for the poet Coleridge and his contemporary Thomas de Quincey. Opium derivatives and synthetic analogues—including heroin itself—had originally been marketed as ‘harmless’ substitutes. The pioneer of palliative care, Dame Cicely Saunders, first promoted effective doses of opiates for terminal cancer, and introduced hospices where this could be practised. However, for every page of this book that covers such familiar ground, I found many that introduced me to new information. Some of this comes as a shock. In Victorian times, for example, opium consumption was almost universal in England. It was sold as a soothing medicine for babies, and added to beer for farm workers. In the first world war, a large number of fighters in the trenches were sustained by opium. When the French Army mutinied in 1917, it was directly because supplies of morphine were withheld from the troops.
Opium and war
Dormandy's unflinching coverage of war and its relation to opium is probably the greatest strength of his book. In a chapter entitled ‘The most wicked of wars’, he gives an account of a singularly cynical campaign carried out by the British empire in the mid-19th century. This was the destruction of China as a viable state, in two wars fought for the explicit purpose of sustaining profits and corporate tax revenue through the sale of opium grown by British companies. In the course of these ‘opium wars’, the British army razed and looted the emperor's summer palace in Beijing. It had been one of the wonders of the world—a city in itself, containing lakes, mock mountains, gorges, bridges, a botanical garden and a zoo. It was also the repository of 3000 years of international arts and crafts, including ceramics, carpets, textiles, furniture, paintings, gold ingots,, bronzes, precious stones and an incomparable library. Its destruction was the equivalent of burning down all the royal palaces and museums in central London. The sacking of the palace, and the massacres that accompanied it to preserve the British opium industry, affect Chinese perceptions of the West to this day.2 Dormandy points out how ironic it was that the Chinese victims of these events became characterised as ‘the yellow peril’ for later bringing their addictions, and their opium, to the USA. He also describes how thousands died on the journey there, on what were effectively slave ships, or perished later in the gold mines of California.
Looking at more recent events, Opium examines the part played by the drug in the Vietnam war and the interminable conflict between the western powers and Afghanistan. Almost from the start of the 10-year conflict in Vietnam, ‘opium and its derivatives were the props of increasingly venal regimes in Saigon’. Working with Corsican gangsters, the CIA provided armed back-up for supplies to the native market and the US army. By 1972, 85% of soldiers were being offered heroin within a day of arrival, and 37 000 were addicts. Trade was open and supervised by the President's intelligence chief. GIs sent large lumps of heroin back home, sometimes buried in the wounds of a corpses in body bags due for repatriation. Dormandy presents a scarcely more reassuring picture of the current state of affairs in Afghanistan, which he characterises as ‘a 21st century narco-state’. In 1970, the country produced 700 tonnes of opium a year. After the Russian invasion destroyed peacetime agriculture, this rose to 4600 tonnes. When the Taliban defeated the Russians with US support, this dropped right back to 185 tonnes. Since the US reversed its support for the Taliban and staged its own invasion, it has risen to record levels. In 2010, around 80% of the police and 60% of the army were reckoned to be on the take.
Dormandy offers no easy solutions for anything—from the clinical challenges of addiction to the repeated eruptions through the recent history of opium-fuelled wars. Yet while admitting it was impossible for him to end the book on an upbeat note, he also argues that unmitigated gloom would be unjustified. Through biotechnology, the opium fields may become redundant. In practical politics, ‘the less bad may be allowed to replace the bad’. I hope he is right, and it becomes commoner to prescribe opiates as a relief from suffering, rather than to find they have caused it.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.