James F Maddux David P Desmond

OPIOIDS AND OPIOID CONTROL: HISTORY Throughout recorded history and in most parts of the world, OPIATES have occupied a central place in medicinals. They have been used popularly against a wide range of ills and to produce calm or well-being. Opiates are renowned for their powerful ability to relieve PAIN. They also have been used for their PSYCHOACTIVE properties and, within the last 100 years, have come to symbolize the problems with attempts to control drug use through legislation and enforcement. (Technically, opiates are a subset of the OPIOIDS, which also include synthetic agents and naturally occurring peptides that bind to opioid RECEPTORS found in certain animal species.)

The OPIUM poppy (Papaver somniferum) grows easily in semiarid parts of the Middle East and southern Asia, including dry or steep locales where other crops are difficult to cultivate. For thousands of years, farmers in these regions have grown the poppy as an important staple crop. For traditional poppy farmers, opium is a cash crop that supplements an agricultural livelihood. The entire plant is used: Poppy seeds are baked into breads, or oil for cooking or fuel is extracted from them and the body of the plant is fed to cattle. The labor-intensive aspect of collecting the sap for sale means that whole families are pressed into service at harvest time. The desire for opium in other parts of the world has long made it an important commodity in international trade networks.

References to opium appear in inscriptions and texts of ancient Sumer, Egypt, and Greece. The Greek physician Galen, in the second century C.E., noted that opium cakes were widely sold in Rome. This observation highlights an important difference between drug use before the twentieth century and contemporary drug use. Currently, drug use is divided into medical and nonmedical (or recreational) uses. Nonmedical use for opiates is banned in most countries, and persistent demand fuels a large and vigorous illicit trade. Medical uses are defined exclusively by physicians, and consumption of these drugs is allowed only in the context of treatment by a physician.

The sharp separation between medical and nonmedical uses of drugs is comparatively new in human history, although attempts to control drug use legislatively are not. In the past, physicians constituted only a small group of specially trained professionals who found their clientele primarily among the rich and powerful. A wide range of healers provided different kinds of health care; for example, in Europe from the Middle Ages to about the mid-nineteenth century, apothecaries prepared and sold drugs to anyone seeking treatment. Apothecaries consulted with the patient, helping diagnose an ailment and suggesting a remedy, but they charged a fee only for the sale of the drug.

Opium became an important European drug in the sixteenth century. During the Middle Ages, the severing of ties between Europe and the Middle East meant that large amounts of opium were not shipped to Europe. In the Middle East, however, the ancient Roman and Greek texts remained important sources of knowledge, and medical, as well as scientific and mathematical, theories were developed and debated among scholars like the Arab physician Avicenna. In these Moslem countries, where alcohol was absolutely forbidden, both opium and cannabis were widely used.

During the European Renaissance, renewed ties with the Middle East brought the ancient texts and their Arab interpretations to the attention of Euro pean scholars. Galen, who had systematized humoral theory in his writings, was recognized as an important authority in sixteenth- and seventeenth-century Europe. Galen's views were challenged by the sixteenth-century Swiss physician Paracelsus, who favored chemical remedies (such as mercury) to herbal ones. Paracelsus valued opium highly. He devised a mixture of alcohol, opium, and other ingredients that he called ''laudanum'' (from the Latin for ''praise'') to suggest its superiority.

Thomas Sydenham, the influential English physician, wrote in 1680: ''Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium. ' This valuation of opium (and later of its derivatives) has been repeated by physicians in the centuries since as ongoing testimony to the drug's central role in medical treatment.

The medical use of opium grew more widespread in eighteenth-century England; for example, the relief of pain at the time of death was seen as an important adjunct to preparing the patient for death in a blessed state of peace. England was an important commercial power in this period, and new kinds of goods from distant parts of the world became increasingly plentiful. Opium was a valuable commodity, and, as such, it was handled commercially like any other. Individuals seeking to treat themselves for aches or ailments, or wanting to relieve drudgery or sleeplessness or persistent coughs, could buy pellets of opium from various merchants, innkeepers, or apothecaries. This pattern persisted through most of the nineteenth century, although by the late eighteenth century a particular effect of chronic opium consumption was described: If a habitual user stopped taking the drug, a clearly recognizable syndrome of symptoms ensued. These included runny nose, tearing, sweating, aches, muscle tremor, vomiting, and diarrhea. These problems were seen as an expected difficulty connected with taking medicines; they were not portrayed as a unique and devastating kind of problem that threatened the social fabric.

In the United States, also, opiates were freely sold. In the first half of the nineteenth century, neither medications nor medical practice were regulated. During the presidency of Andrew Jackson, antimonopolistic sentiment had led many states to repeal licensing requirements for physicians, on the grounds that such licenses created artificial elites. Many people saw no physician at all; they treated themselves or their family members with homemade or purchased remedies. Taking charge of one's own medical care also reflected the kind of broadened democratic spirit that characterized the Jacksonian age. In home treatment, opiates were valued for their wide-ranging effects, including quick and dramatic improvement in how one felt. Physicians also administered opium generously as part of the heroic brand of therapy favored in the nineteenth century. Based on humoral theory, ''heroic therapy'' sought to provide clear evidence of its effects on body fluids by promoting fluid discharges. Emetics and cathartics were the hallmarks of such practice, but the ability of opiates to produce sweat in addition to their other valuable effects made them a component of heroic therapy.

For individuals who appeared chronically weak, perhaps as the result of lingering fever, opium improved spirits and energy and was considered by many medical practitioners to have a STIMULANT effect (although it is now classed as a DEPRESSANT). Individuals who took the drug to relieve vague feelings of unease, or in the absence of serious medical conditions, were said to take the drug for its stimulant properties.

Rapid industrialization caused profound social shifts in England in the first half of the nineteenth century. People whose families had worked on the land for generations became part of the first large-scale factory work force. Working conditions were brutal; men, women, and children worked 14 hour days, 6 days a week. Working women often had to bring young children to the factory with them. For working people, opium was an easily available source of relief for many complaints of both adults and children.

Early in the nineteenth century, Thomas De Quincey and Samuel Taylor Coleridge wrote about opium-induced reveries. Although their works were widely read, their opium use was treated more as a curiosity than a cause for alarm. The earliest concerns about excessive or indiscriminate opiate use centered on adulteration or on deaths due to accidental OVERDOSE. These were voiced by a new group of professionals, public health workers. Extensive surveys of health conditions in England in the 1840s both highlighted problems and created opportunities for government and professional workers to expand their professional arenas. At the same time, the old three-rank system of health-care givers, in which physicians treated the well-to-do while surgeons and apothecaries met the health needs of those of more modest means, was giving way. Surgeons and physicians joined a unified healing profession, whereas pharmacists prepared and sold drugs without providing diagnostic or therapeutic advice. As physicians worked to increase their professional authority, they sought to gain control over the use of drugs, defining them as medicines that only the medically trained could use or prescribe with safety. Toward the middle of the nineteenth century, a few physicians expressed concern about opium use for its "stimulant" effects. These voices foreshadowed an alarm about nonmedical use of opiates that would transform how this behavior was viewed. In the meantime, the 1868 Pharmacy Act called for precise labeling of any preparation containing opium.

The incidence of addiction also worried some observers, and this phenomenon became increasingly visible in part as a result of new pharmacological discoveries and changing medical technology. In 1806, Frederich Sertürner of Hannover, Germany, announced that he had isolated the chief active component of opium. He named this new drug MORPHINE, after Morpheus, the Greek god of dreams. Morphine was the first drug compound to be isolated from the plant that contained it, and as such it marked the first step in the development of scientific pharmacology. Drug effects could not be precisely described and measured until individual compounds were isolated. The isolation of CODEINE followed in 1832. In time, the systematic modification of the molecular structure of such compounds would be an important source of new medications and the basis of the modern pharmaceutical industry.

In the 1840s, the invention of the hypodermic syringe provided a new means of administering drugs. Morphine was among the first drugs to be administered by syringe, and the immediate introduction of the dose into the bloodstream provided stronger and faster drug effects than by swallowing and digesting the drug.

During the American Civil War (1861-1865), the combination of the more potent morphine, the hypodermic syringe, and wartime conditions contributed to widespread hypodermic morphine use. Large numbers of wounded soldiers and relatively few physicians meant that many soldiers were given syringes and supplies of morphine to treat their own pain. Many soldiers inevitably became addicted. Following the war, some of these soldiers phased out opiate use as their wounds healed, while others continued their pattern of morphine use for years. In the postwar period of industrial and commercial expansion, a wide variety of preparations containing opium were sold through vigorous advertising in an unregulated market. Physicians prescribed opiates, including morphine and codeine, for a wide variety of conditions. Many preparations were advertised specifically for women's health problems or for children bothered by colic or teething pain.

After 1850, Chinese laborers were brought to the American West to work on railroad building and other forms of gang work. As they moved away from these forms of labor, some Chinese took up placer mining in the Sierra Nevada or settled in Pacific coast cities like San Francisco. There, as white laborers sought to exclude them from the labor market, many opened and operated small businesses. The Chinese brought with them the practice of smoking opium to induce a 2 to 3 hour state of dreamy relaxation. Prejudice against Chinese people was based largely on fears that they would displace white laborers by accepting wages that white people considered to be below subsistence level; this prejudice focused on Chinese customs such as opium smoking. The U.S. Congress passed several laws in the 1880s to reduce the importation of opium intended for smoking into the United States.

In 1898, the Bayer company of Germany began marketing the newly trademarked drug Heroin, produced by modifying the morphine molecule. At first, HEROIN was valued for its apparent ability to cure morphine addiction; a dose of heroin quickly relieved all symptoms associated with morphine withdrawal. Within a few years, heroin's addic-tiveness was recognized and physicians stopped prescribing it, despite its effectiveness in relieving pain and coughing.

For many who became addicted through self-medication, addiction was a source of shame of which they could not free themselves. They sought treatment in privately run clinics that promised anonymity and offered little more than a place to rest while they went through withdrawal; or they purchased purported cures that, in fact, merely contained more opiates. Others continued to take opium or morphine and managed their jobs or other responsibilities as long as their drug supply remained uninterrupted. The initial response to rising rates of addiction was to blame unscrupulous medicine merchants and physicians who administered opiates too readily.

In the United States, the concerns about adulteration, overdose, and addiction associated with an unregulated drug market became acute around the turn of the twentieth century. In the context of Progressive Era reform, the 1906 Pure Food and Drug Act required that any medication containing opiates state their presence and the amounts on the label.

In both the United States and England, what is now called recreational use of drugs emerged around the 1890s. People began taking opiates for pleasure, or to provide a novel experience, in a social setting with no medical overtones. Rising alarm about drug use as a particularly dangerous kind of social problem dates from this period, which also saw the rising political power of the Temperance Movement and its efforts to enact a total prohibition on the use of alcohol. Unfamiliar drug-use practices provided an additional focus for social anxieties in a time of rapid economic change. A Protestant middleclass ethos helped burgeoning new groups of professionals and business people adjust to new kinds of economic opportunity in an industrial age. Behaviors that challenged that ethos with pleasure seeking, new modes of entertainment, and unfamiliar druguse practices proved disturbing.

In the 1890s in England and the United States, small numbers of artists and bohemians, seeking to challenge what they saw as restrictive Victorian artistic and social standards, visited Chinese opium dens where they learned to smoke opium. For some Chinese in London or Liverpool, opium smoking provided a means of relaxation from a life of hard work in an alien land. As the existence of opium dens became more widely known, however, images of ghostlike, numb pipe smokers began to appear in popular literature. The middle- and upper-class pleasure seekers who smoked opium prompted a compassionate response, but British working-class use of opium was viewed as an indication of laziness, poor child-rearing habits, or loose morals.

In the United States, the 1880s and 1890s brought waves of new immigrants from southern and eastern Europe—and they brought new cus-

In this drawing from the Illustrated London News, July 1857, workers at Hong Kong harbor transfer bales of opium from one ship to another for export to the West. (© CORBIS)

toms to the American cities they settled. By the early 1900s, sniffing heroin, for example, had become a practice of some young adults in urban neighborhoods crowded with large immigrant families or for some single adults making their way alone in a new industrial setting.

Rising concern about opiate use in this period was only partly a reaction to incidence of opiate addiction, which, with alcoholism, was classed as a psychiatric condition called inebriety. In the late nineteenth century, many troubling conditions were redefined as diseases, especially as forms of psychopathology, and opiate addiction was among them, although many physicians even decades later saw addiction as resulting from a moral failing.

Worldwide missionary activity also resulted in concerns about opiate addiction. Christian missionaries in China and the Philippines, for example, believed that opiate addiction among the local populations helped explain what they perceived as economic backwardness. Like some temperance advocates in the United States, reformers concerned about addiction portrayed it as a form of slavery that followed a collapse of moral will. In such a framework, opiate addiction appeared as a scourge to be eradicated. Between 1911 and 1914 reformers met at The Hague to urge worldwide control of opiate supplies so as to prevent any nonmedical use of the drugs. Some countries joined in signing and ratifying a treaty that marked the first attempt to develop a coordinated international system for controlling worldwide opiate supplies. The U.S. representatives to these meetings were embarrassed by the lack of any U.S. legislation for controlling access to opiates. A lobbying effort to bring U.S. legislation into line with the goals of The Hague resolutions led to passage of the Harrison Narcotics Act in 1914, the first U.S. law enacted to control who could buy a drug. The act banned sale of opiates and cocaine except for use by physicians or through a doctor's prescription. The American Medical Association (AMA), sensitive to charges that physicians' overprescribing of opiates was the chief cause of addiction, supported the legislation.

Following implementation of the HARRISON Narcotics Act in 1915, health authorities in several American cities were worried that the sudden lack of opiate supplies for addicted individuals would create great personal stress and a possible public crisis. They opened clinics that were intended to dispense opiates to addicts so that they would not go suddenly into withdrawal when legal supplies were cut off. In many cases, the mission of a clinic was unclear: Were patients expected to reduce their doses gradually and wean themselves off opiates, or would some be permitted to continue to maintain their addiction by means of opiates supplied through the clinics? The U.S. Treasury Department, charged with enforcing the Harrison Act, moved vigorously to enforce it by charging certain physicians with the excessive prescription of opiates and by arguing in court cases that the act specifically disallowed addiction maintenance. In 1919, the Supreme Court ruled that the Harrison Act meant that physicians could not prescribe opiates to addicts except as part of a shortterm program of detoxification. Again, the AMA agreed. Armed with this legal support, the Treasury Department continued its enforcement activities against the maintenance clinics, and by the mid-1920s all had been closed.

The Harrison Act was envisioned by its proponents as part of a planned worldwide system of treaties in which each country that imported opiates would allow only the amounts needed for medical treatment to cross its borders. Opium-producing countries and the European countries where, in this period, most of the world's opium was refined into drugs like morphine or codeine would also cooperate to limit supplies of the drug. This approach to drug control has characterized the drug policies of most countries ever since.

Meanwhile, morphine and heroin use became part of a new urban social scene that included new kinds of entertainment. Concerns about opiate addiction shifted from compassion for innocent victims of improper medication to alarm about new centers of vice in urban neighborhoods. Inner cities became populated with groups whose social and political behaviors worried some business leaders, middle-class reformers, and workers who felt their jobs were threatened.

The passage of the Harrison Act was followed by the creation of federal enforcement bodies to prohibit unauthorized entry of opiates into the country, and to arrest and convict unauthorized sellers and possessors of opiates. In the 1920s, psychiatric theory held that chronic addicts suffered from personality deficits that caused them to feel inordinate pleasure from opiates and thus become mired in addiction. Opiate addiction was now viewed as both a medical and a criminal problem. The creation of the Federal Bureau of Narcotics in 1930, and the appointment of HARRY J. ANSLINGER as its head, moved drug enforcement out of the Prohibition Unit that oversaw enforcement of the Volstead Act. Following repeal of alcohol prohibition in 1933, the Federal Bureau of Narcotics continued to carry out the enforcement of the prohibition of opiates and cocaine. Anslinger was a skillful administrator with a background in diplomatic service. He oversaw American participation in the activities of the League of Nations' Opium Advisory Committee, which furthered the work on international control of opium supplies that had been initiated through the Hague Opium Treaty. On the domestic front, Anslinger managed an efficient team of nationwide enforcement officials. Believing that harsh and early punishment would be effective deterrents, he supported increasingly severe punishments for drug offenders, including mandatory minimum sentences for first offenders. For decades, the ''drug problem ' remained in the background of public consciousness as a kind of exotic problem associated with a city world of jazz, marijuana, and beatniks, but the threat carried enough symbolic weight to cause penalties for drug trafficking and possession to be stiffened in 1951 and again in 1956. Anslinger remained the U.S. government's chief drug-enforcewment official until his retirement in 1962, when, in both medical and legal circles, a new generation of observers were urging less punitive responses to drug offenses and greater emphasis on medical approaches to treating addicts.

The British approach to controlling opiate use in the twentieth century proceeded along a policy basis that was different from that of the American approach, despite some similarities in legislation. The Dangerous Drugs Act of 1920, like the American Harrison Act, restricted the use of opiates to legitimate medical needs. However, the British government did not seek to define the limits of those medical needs. The government-appointed ROLLESTON Committee, which met in 1924, recommended that addiction be regarded as an illness to be treated by physicians. Reacting in part to perceived difficulties in enforcing America's prohibitions of both alcohol and opiates in that period, the Rolleston committee members sought to avoid stimulating an illicit market by banning opiates. Rather, they favored allowing individual physicians to prescribe opiates to selected addicts—that is, they recommended a policy of addiction maintenance. British policy was also conditioned by the demographics of opiate use in Britain, which differed from patterns in the United States. In Britain, opiate use continued to be associated with affluent bohemianism and those addicted through legally prescribed medication, and the powerful stigma against addicts that characterized the American scene did not develop to the same degree in Britain. In such an atmosphere, nonpunitive policies appeared appropriate.

In the 1960s, startling new patterns of drug use brought the issue to mainstream consciousness in the United States and throughout Western Europe. Since the nineteenth century, the leaders of American reform efforts aiming to curb drug use had typically couched their rhetoric as concern about use patterns among specific population groups— foreigners (as in opium use by Chinese people) or the working class. Now, illicit drugs were typically being used by young, white, and middle-class persons.

Events of the 1960s prompted a generation of young people raised during the prosperous 1950s to question the ideals of the relatively calm and affluent world that they knew. These events included the ongoing civil-rights movement, the assassinations of President John F. Kennedy, Martin Luther King, Jr., and presidential candidate Robert F. Kennedy, and the escalating war in VIETNAM. As they questioned and challenged the establishment, young people disregarded old prohibitionist messages about illicit drugs; at the same time that they sought to forge new values, they also hoped they could eliminate the superficial and hypocritical aspects in American life. MARIJUANA and psychedelic drugs most closely symbolized the new spirit, but young people buying drugs on the illicit market and sharing lore about highs also encountered amphetamines and opiates.

For the young men who went to Vietnam to fight the war, the ready availability of heroin provided one possible avenue of escape from the horrors some of them experienced and witnessed daily (although boredom was often reported as a common motive for use). Southeast Asia remained an important source for the world heroin market, even more so as the trade from Turkey through southern France became hampered by enforcement activity. It was relatively easy for many returning veterans to stop using heroin once they returned to the United States. The men came back, however, after fighting a losing war to a United States deeply divided over the conflict. Receiving little welcome, many veterans had difficulty in readjusting to civilian life; for some of these, continued drug use remained part of a web of problems made up of chronic medical conditions or difficulties in finding work, although opiate use specifically was remarkably uncommon.

In 1972, President Richard M. Nixon was re-elected on a platform that included bringing an end to the war and responding to growing American fears about crime. He united these concerns by increasing enforcement resources directed against drug use. In 1971, Nixon had proposed the most significant federal drug-policy initiatives since the passage of the Harrison Anti-Narcotic Act of 1914. He announced the creation of the Special Action Office for Drug Abuse Prevention (SAODAP). This office, administratively located in the White House and headed by Jerome H. Jaffe, M.D., led an expanded federal funding for drug treatment and special programs to identify and treat addicted soldiers returning from Vietnam. Jaffe had been director of an innovative program in Illinois that offered a range of treatment services, including methadone maintenance. The previous U.S. policy toward opiate addiction, which placed emphasis on law enforcement, was for a time replaced by one that emphasized concern for treatment and prevention in addition to control of the drug supply. Beginning in 1963 in New York, Vincent Dole and Marie Nyswander had demonstrated that longtime heroin users, stabilized on daily doses of oral methadone and supported with a range of rehabilitative services, showed reduced criminal activity and improved functioning in social and employment areas. Nixon came to believe that methadone maintenance would provide a cost-effective means of reducing the money-seeking crimes committed by street addicts. Previously viewed as an experimental treatment, methadone maintenance, though subjected to special regulations, was made an accepted element in the treatment of opiate addiction. In the same legislation that created the Special Action Office, Congress included language that authorized the formation of the National Institute on Drug Abuse to coordinate federal funding of treatment services and research on drug abuse.

Meanwhile, in the 1970s, under federal leadership, treatment programs were expanded and new ones created in cities across the United States. Increasingly, those running the programs encountered patients who did not fit the model of the criminally involved longtime heroin addict. Younger patients, more women, and those using a variety of drugs reflected changing U.S. drug-use patterns. As these patterns were recognized, opiates ceased to dominate images of drug abuse in both the popular mind and in policy circles. Rather, opiates became just one group among many that were traded on the illicit market and used for philosophical, lifestyle, political, recreational, and even habitual reasons.

The Controlled Substances Act of 1970, also passed at Nixon's initiative, reformulated how drugs were assigned legal status. The act created five schedules for categorizing psychoactive drugs, ranging from those considered to have no medical use and high risk of abuse to those having important medical use and only a mild risk of abuse potential.

In Britain, as in the United States, drug users in the 1960s and 70s experimented with a growing range of drugs besides opiates. New patterns of chronic drug use, new, flamboyant behaviors symbolized by the lives of celebrities and rock stars, and a sharp escalation in the absolute numbers of heroin addicts prompted some divisions in Britain's medical community about the wisdom of continuing Britain's nonpunitive maintenance policy toward opiate addiction. Some physicians became unwilling to treat addicts, whereas others remained committed to a purely medical approach to addic tion with maintenance as an important component of the policy. In 1968 new laws were passed that limited the role of the general physician in the prescribing of heroin and that established a system of clinics supervised by specialists.

The early 1980s advent of ACQUIRED Immunodeficiency Syndrome (AIDS) has added a new dimension of concern about drug use by injection, the preferred mode of administration of many heroin users. Because sharing used syringes can transfer the human immunodeficiency virus (HIV) from one person to another, drug use by injection has been named a high-risk behavior for its transmission.

In the late 1990s, heroin addiction once again is escalating and has moved from center city shooting galleries and dope houses (places people gather to use drugs) to more middle-class neighborhoods. There has also been a change in the ways people use heroin. Indeed, these changes in use patterns and user groups are comparable to those last seen during the Vietnam-era epidemic of the late 1960s and 70s. The so-called new heroin users are younger, smokers and snorters.

The new millennia heroin user is much less likely to start out injecting heroin. Snorting and smoking heroin is not, however, without inherent health risks. Heroin snorters risk neurologic complications, respiratory infections, and problems associated with other forms of heroin use, such as dependence, withdrawal, and vulnerability to future injection drug use and its associated diseases. Heroin smokers share these same health risks plus the added problem of respiratory infections through ''shotgunning'' or inhaling smoke and then exhaling it into another individual's mouth. This practice has the potential for the efficient transmission of respiratory pathogens, particularly tuberculosis.

Most of these young heroin users move on to injection drug use at some point in their drug using careers. In the absence of an effective treatment or vaccine, efforts to control the spread of HIV and hepatitis C (HCV) infections depend on reducing risk behaviors. Public health interventions have taken the form of prevention campaigns employing the media, educational groups or seminars, and street outreach workers. However, we also know that knowledge of health risks is not enough to help injection drug users to change their behaviors.

The availability of drug-using paraphenalia and the problems associated with finding clean and sterile equipment play a major role in disease transmission. One response has been to reduce the sharing of paraphernalia through the creation of needle exchange programs that distribute sterile needles and syringes, as well as other drug-using equipment. Assessments of the impact of such programs, in Australia, Europe, and in the United States, suggest that syringe exchanges play an important and significant role in reducing the rates of sharing for drug-using equipment.

All modes of heroin ingestion increase heroin users' vulnerability to hepatitis infection through the sharing of drug-using equipment (e.g., needles, straws, pipes, receptacles to cook or mix drugs). The spread of HIV/AIDS, hepatitis, tuberculosis, and other pathogens and infections among youthful drug-using populations poses not only serious public health threats, but also potentially large increases in public and private health-care costs.

Opiates remain important medication for the treatment of pain, cough, and diarrhea. Recent discoveries that opiates achieve their effects by mimicking compounds occurring naturally in the body (e.g., Endorphins and Enkephalins) have spurred exciting neuroscience resesearch about how the brain works. After millennia of use, then, opiates continue to be one of the most interesting classes of drugs.

(SEE ALSO: Asia, Drug Use in; Britain, Drug Use in; Chinese Americans, Alcohol and Drug Use among; Dover's Powder; Shanghai Opium Conference; Terry and Pellens Study)

BIBLIOGRAPHY

Berridge, V., & Edwards, G. (1981). Opium and the people: Opiate use in nineteenth-century England. New York: St. Martin's Press. COURTWRIGHT, D. T. (1982). Dark paradise: Opiate control in America before 1940. Cambridge: Harvard University Press. INCIARDI, J. A. & Harrison, L. D. (1998). Heroin in the age of crack-cocaine. Drugs, Health and Social Policy Series Vol. 6. Thousand Oaks, London and New Delhi: Sage Publications. Morgan, H. W. (1981). Drugs in America: A social history, 1800-1980. Syracuse: Syracuse University Press.

Musto, D. F. (1987). The American disease: Origins of narcotic control. New York & Oxford: Oxford University Press.

SCHUR, E. M. (1963). Narcotic addiction in Britain and America: The impact of public policy. Bloomington: Indiana University Press.

STOLLER, N. E. (1998). Lessons from the damned: queens, junkies and whores respond to AIDS. London and New York: Routledge.

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