Opium was one of the most widely used medications of the 1800s, and the results of this use were devastating. Opium was first identified as the active ingredient in poppy seeds in 1806, and it was purified shortly thereafter. Morphine, as the purified substance was called, began to be widely used as a medication after the hypodermic needle was invented in 1853, which was just before the Civil War. This, along with the repeated mass casualty events of the war, created the perfect storm of morphine use and subsequent abuse, which led directly to America’s first major opioid crisis.
During the war, morphine had plenty of important and medically justified uses, even by today’s standards. The Civil War was a brutal affair, and there were many battle-related injuries. The surgery of choice for gunshot wounds to extremities were amputations. Contrary to popular belief, anesthetics of the day were not a shot of whiskey and biting down on a stick, but a combination of chloroform and morphine, which was widely used as a local anesthetic. The problem is that these were incredibly painful surgeries and required repeat dosing of morphine to keep the pain under control. Strict guidelines regulating its prescription and use did not exist at the time. In addition, morphine was marketed as a “less addictive” form of opium when it was first purified, much like the marketing practices of oxycodone, the harbinger of the modern opioid epidemic. Many of the battles of the Civil War depended simply on manpower because of the battlefield tactics at the time. Given the rate of casualties during battles, this manpower was a scarce resource. Soldiers were asked to return to the front line after major wounds that did not require amputation, such was the case of John Goolrick, who was shot in the left leg during the siege of Petersburg. He was prescribed morphine, and shortly thereafter returned to fighting.
In addition to the value of pain relief that morphine provided, the “side effects” of morphine were used as an indication for prescription during the war. For example, one of the most common killers during the war was diarrhea, and there were around 57,000 deaths and 1,528,098 cases of that disease alone. When we prescribe opiates for pain relief now, we warn patients to maintain a high fiber diet and take stool softeners because of risk of constipation. This effect was used for symptom relief in these patients. This was also the case for soldiers with a cough, as opiates are also an effective cough suppressant. However, such liberal prescription of a highly addictive drug set the stage for what happened after the war.
Soldiers who left the war addicted to morphine were not treated with empathy and kindness required for addiction treatment in the years following the war. It was not even addressed as an addiction, and it was known to the public as “opium slavery” or “morphine mania.” The harshness of the terms used to describe addiction gives a glimpse to the stigma and social isolation that former soldiers suffered. It was viewed as unmanly and weak-willed. As a result, former soldiers often suffered with their addiction in silence, for fear of being shunned by society. Treatment options for opioid addiction were not particularly enticing, as well. They included quitting morphine “cold turkey” and dealing with the devastating symptoms of withdrawal as well as a stay in a mental asylum. Discharge from mental hospitals were not frequent, and they functioned more like prisons than treatment centers. Even after undergoing torturous treatment, relapse was common.
The plight of the post-war addict is exemplified by the story of the aforementioned John Goolrick, through letters to his wife’s family. It is rare to have an honest account of the struggle caused by addiction because of the stigma of the time, as it was largely hidden from peers. Despite his addiction, he became a lawyer after the war in Fredericksburg, Virginia, and maintained a social life in the community alongside his wife. However, his addiction grew stronger as time wore on, and almost 30 years after the war ended suffered a mental breakdown due to morphine which prevented him from practicing law. The Goolrick’s social circles began to fall apart as the townspeople learned of his addiction, furthering the troubles that they were facing at home. Even a man of prominent social stature was not given sympathy in that time, the stigmas surrounding addiction were too strong. Goolrick was eventually institutionalized, which also carried a stigma. As we know, institutionalization and withdrawal of morphine are not effective strategies to reach remission, and John wound up relapsing several times in his life. This is a great example of how morphine addiction was stigmatized, and the isolation only worsened the condition of those addicted.
The effect of addiction in the aftermath of the Civil War had an impact on the medical industry. Understandably, soldiers who suffered from addiction often blamed the providers who prescribed the medication in the first place. This fostered a sense of distrust in surgeons and medical providers as we understand them today. This phenomenon still happens today, as we saw the distrust in pharma and medical practice rear its head publicly with the anti-vaccine movement. However, this sentiment was a much bigger problem back in the late 1800s and early 1900s, as modern medicine did not have a monopoly on patient care as it largely does today. Methods that we may see as fringe or experimental now were vying for public support, and the first opioid crisis helped them gain steam. It is interesting to think about how this crisis could have completely changed the landscape of medicine as we view it today.
Opium was one of the few medications that were available to physicians during the Civil War that was effective at treating the many maladies that soldiers suffered from. As a result, the medication was overprescribed, leading to large scale addiction in soldiers returning from battle. This had devastating effects on those soldiers’ lives and changed how we practice medicine.
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Sources cited
https://virginiahistory.org/learn/opiate-addiction-civil-wars-aftermath
https://library.medicine.yale.edu/blog/great-risk-opium-eating-how-civil-war-era-doctors-reacted-prescription-opioid-addiction
https://michaelshouse.com/opiate-rehab/history-of-opiates/#:~:text=The%20earliest%20reference%20to%20opium,opium's%20usefulness%20as%20a%20narcotic.
https://www.pbs.org/mercy-street/uncover-history/behind-lens/disease/#:~:text=At%20the%20beginning%20of%20the,to%20these%20most%20disabling%20maladies.
https://www.c-span.org/video/?477833-1/civil-war-veterans-opiate-addiction
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