In 2011, the Centers for Disease Control reported that prescription drug abuse had reached epidemic proportions in America.  Deaths from prescription opioids alone outpaced deaths from heroin and cocaine combined, and prescription drugs overall vied with car crashes as the most common cause of accidental death.  While more recent reports suggest that the problem may have stopped growing or even begun to wane since 2013, prescription drug overdoses remain America's leading cause of injury death, and the apparent levelling off of prescription opioid abuse has been accompanied by an increase in non-medical opioid use and associated harms.  Most observers identify these problems as a recent phenomenon originating in the 1990s.  This presumed novelty plays a key role in the epidemic's most culturally compelling narrative:  that addiction has escaped its traditional home among the nonwhite urban poor, and has, via the medicine cabinet, run amok in respectable white suburbia, producing (as one typical news report put it) a "new breed of addict" in "the least likely corners of America."

 

Both the epidemic and the shocked reactions to it, however, have a long history.  As even a cursory review of historical literature demonstrates, problematic use of legally manufactured sedatives, stimulants, and narcotics (or for convenience despite the anachronism, "prescription drug abuse") has regularly dwarfed illicit drug abuse for over a century, and drug authorities and popular media have been discovering and re-discovering this epidemic for the better part of the 20th century.  By recasting prescription drug abuse as a longstanding phenomenon rather than a recent aberration, this story raises important questions about the way we understand and manage American drug problems.  It also provides a rich historical laboratory of past experiences and policies to inform scholars, health care professionals, policymakers, and law enforcement agencies as they grapple with those problems today.

 

Two of the most important goals of America's drug infrastructure are encouraging therapeutic use of medicines, and discouraging abuse of drugs.   The long persistence of prescription drug abuse, which stands athwart the two, suggests a range of practical and conceptual problems with this framework.  It highlights, for example, the difficulty of disciplining a commercial pharmaceutical industry reliant in part on the mass marketing of sedatives, stimulants, and narcotics.  It poses in stark terms the dilemmas of physicians' prescribing autonomy--necessary for serving patients' right to treatment and relief, but also a vehicle for iatrogenic addiction.  It exposes the arbitrary and circular logic behind fundamental binaries such as "medicines" and "drugs," and "therapy" and "abuse," by tracking dramatic changes over time in the medical, legal, and cultural status of specific drugs and types of drug use (the only consistent definition of abuse has been "non-medical use"--a protean term to be sure ).  And by including large populations of prescription drug consumers who do not fit easily into standard medical models or popular stereotypes of addiction, it brings new complexity and new evidence to heated debates over the nature of addiction as a medical and a social problem.

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When seen in light of its long history, in other words, prescription drug abuse stands not just as a threat to the public health, but as a threat to the conceptual and practical tools we use to define and manage the public health in this context.  We need these tools:  any realistic effort to grapple with addiction as a social problem will almost certainly involve pharmaceutical companies, physician prescribing, and binaries such as "therapy" and "abuse."  To wield them effectively, however, we must understand them; and to understand them, we need history.  For these are not only biomedical formations.  They are also fundamentally historical, built and rebuilt over time in response to a wide variety of contexts--especially, in America, the social hierarchies of race, gender, and class.  Present-day drug use, drug research, drug therapy, drug policy, and drug enforcement occur within the complex legacies inscribed by this history, and to make sense of drug problems--both licit and illicit--we must reckon with those legacies.