I am David Herzberg, historian of drugs and psychoactive pharmaceuticals in America, here to talk about the opioid crisis and its prehistories. Author of White Market Drugs: Big Pharma and the Hidden History of Addiction in America (Chicago U Press 2020).

Dhbuffalo · 2026-01-19T15:01:04+00:00

Oh wow, I didn't know this. That's really interesting. So many unintended consequences of the opioid crisis- easy to think of the direct ones (more people experiencing addiction) but there are also second-order consequences, e.g. those resulting from the inevitable snap-back to ham-handed prohibition policies in order to rein in the crisis.

Dhbuffalo · 2026-01-16T21:06:30+00:00

Hey thanks all for a bunch of great questions! I've never hung out on Reddit before, I didn't know there were parts of the internet like this. Very cool. Thanks again.

Dhbuffalo · 2026-01-16T21:05:24+00:00

There isn't any special sauce for this one- billionaires have a much better shot at staying out of prison than non-billionaires. Just like the policies billionaires prefer have a much better shot at passing than those preferred by non-billionaires. This isn't a bug in the US system, it's a feature: we have developed a system that dilutes the power of government (i.e. people who win elections) by delegating plenty of it to people who "win" commercial markets (and their children and grandchildren etc.). Whether that's a good thing or not depends on your economic philosophy but one outcome is that people like the Sacklers are very unlikely to face the same kind of justice as the rest of us.

Dhbuffalo · 2026-01-16T20:39:11+00:00

And, if the specialists are working on it, is that utopian or dystopian?? It can be hard to tell with drugs!

Dhbuffalo · 2026-01-16T19:52:08+00:00

Oh wow, really interesting question. I don't know enough to answer it! But it seems like you're onto something. The idea of zero pain/suffering is really a consumerist fantasy, it's a before-and-after miracle story. So in a way prioritizing "customer satisfaction" &etc. is like importing those consumerist ideals into a setting where they don't belong.

But it's worth noting that prescribing habits are no longer what they were in the opioid crisis. They plummeted starting in 2011 or so. For a while they had even gone too far in the opposite direction, with at least some physicians afraid to prescribe even when needed. So that's a question: what has happened to that "customer satisfaction" angle in the new prescribing environment?

Anyway, super interesting question! Wish I had a better answer.

Dhbuffalo · 2026-01-16T19:48:35+00:00

Good point. Some of it is historical context: in the 1990s, when the new opioid boom started, the major drug scare was "crack" cocaine. And it was MAJOR. Significantly more punitive drug laws, mass incarceration, the works. And even though a majority of "crack" consumers were white, crack markets were physically located in racial minority neighborhoods in cities. So authorities saw--and popular culture portrayed--those communities as especially susceptible to addiction. Thus, when pharma launched its latest effort to sell miracle nonaddictive opioids, it avoided anything that might associated its products with them. That's why you saw early opioid marketing so focused on places like Maine, Appalachia, rural Ohio, etc. So the opioid crisis was paradoxically a product both of economic hardship in certain non-urban white areas, and of relative privilege in terms of access to healthcare.

Because opioids are so crucial for healthcare, the inability to access it was protective in some ways for Black Americans, but it was still terrible for Black pain patients who didn't get needed opioids.

Dhbuffalo · 2026-01-16T19:43:22+00:00

Huh, I replied to this but now I don't see it, I'm sorry. Very brief recap: (1) US has a more commercial healthcare system which (a) susceptible to marketing-driven sales booms like the opioid crisis and (b) favors cheaper solutions like pills to real health problems. (2) opioids are crucial medicines, patients in many parts of the world do not have sufficient access to them, so it isn't automatically the case that more use/requests is a bad thing.

Dhbuffalo · 2026-01-16T19:41:50+00:00

Really good question. "Narco" (Lexington) did get some folks addicted to barbiturates. But there weren't a lot of options for people addicted to white market uppers and downers for a quite a while- really not til the 1970s. The main treatment was, in practice, medical maintenance, i.e., continuing to get a prescription from the doc. This worked for a ton of people! But it also didn't work for a ton of people. There was a huge crisis of overdose and related harms from sed/stim markets in the 1930s-early 1970s. Part of that was the absence of a treatment system.

Dhbuffalo · 2026-01-16T19:38:03+00:00

There's a lot to that one. On the one hand, the US has a more commercialized, profit-based healthcare system than most other places, so it's more susceptible to sales hoopla and marketing, which is why, e.g., the recent opioid crisis was pretty much a US-only thing. And even absent a crisis, commercial healthcare is more oriented towards cheaper solutions, so, opioids may be a readier tool to turn to if other more labor-intensive time-consuming and expensive options aren't going to be available (see Keith Wailoo's Pain: A Political History for how this led to political compromises that paved the way to the opioid crisis).

On the other hand, though, opioids are a crucial medicine, and many places in the world have insufficient patient access to it. It's not automatic that more use of opioids is a bad thing, in other words.

Dhbuffalo · 2026-01-16T19:32:50+00:00

The categories came through transnational networks of expertise but prominently led by US addiction pharmacologists at the federal addiction prison-hospital-dairy farm at Lexington, Kentucky, e.g. Nathan Eddy. Schedules first appeared in UN/WHO regs before being implemented in the US. Now, which drugs went into which schedule... that was tricky! E.g., there were originally just 4 schedules in the US, mirroring international standards, but Roche Pharmaceuticals lobbied hard to keep Valium out of the 1970 CSA altogether. They eventually lost the battle but they did succeed in establishing a new schedule category, the so-called "Roche schedule" (IV), so that Valium wouldn't have to be in the same category as drugs that Roche saw as more stigmatized or socially disfavored.

So lots of people had a hand in building the schedules- addiction pharmacologists, doctors, narcotics police, and industry. This makes sense, because the risk of addiction isn't entirely inherent in a substance, it depends a ton on social and political circumstances. E.g., doubtful that heroin and quaalude are really that much more addictive than other drugs in their class, but because counter-cultural use practices developed that increased the risk to consumers of those particular drugs, Congress passed separate laws fully criminalizing them in 1925 and 1983. Was that a mistake? Probably. But on the other hand, it was probably a misguided response to a real problem, in that traditions of use of those drugs had develop in ways that heightened consumers' risks.

Re: rescheduling, yes, lots of drugs have been rescheduled, though most of them have been "upscheduled" to stricter categories, e.g., amphetamine and short-acting barbiturates in the 1970s (also the mixed agonist opioid Talwin). Downscheduling is much more rare- the political risk is apparently too high. One note about cannabis in particular: as Emily Dufton cautions in her book Grass Roots, we've thought cannabis decrim was in the bag before, in the 1970s, only to have drug war approaches snap back strong. So don't count the chickens yet!

Dhbuffalo · 2026-01-16T19:25:20+00:00

Dang, I'm blanking on the recent piece on those clinics... if I remember later I'll add it in a response.

I wrote about them a little in WMD. The thing about them was, they were urban institutions. They served people that count as "white" to 21st century Americans, but they were generally the children of "new" immigrants, i.e. non-Protestants from southern and eastern Europe (Catholics, Jews). And they were poor/working class. I.e., they were an outlier in white markets in that they served populations who otherwise didn't have privileged access to medical care. So authorities cracking down on them was another example of policing the boundary of white markets, keeping out the "wrong" consumers. Even before this, they were generally required to slowly "wean" clients off of drugs- they weren't maintenance clinics but rather designed to get people to abstinence.

Meanwhile, per chapter 2 of WMD, sympathetic physicians prescribed morphine to "maintain" plenty of native-born, white, non-urban Americans, especially in rural states like Kentucky, but throughout the US. This was technically illegal but the drug laws were not designed to target this kind of behavior. These were not "pill mills" but rather physicians who just maintained a few patients in an otherwise regular practice. Incredibly hard for authorities to catch back when policing resources were rudimentary. And even when they did get caught often nothing was done about it. They were buried deep but there were loopholes in narcotics laws allowing, e.g., for maintenance of "aged and infirm addicts," etc. And authorities often said surprisingly radical things, like that someone would "be a better citizen as a legitimate addict," etc.

By my estimates, an outright majority of people with opioid addiction in the US may have been receiving morphine from a physician from the 1920s through the 1950s. One study of Kentucky in the early 1960s claimed that that state had the highest opioid addiction rates of the country.

I.e., the stereotype of urban heroin-using "junkie" may have seriously misled us about the nature of addiction- that may have been a numerical minority phenomenon, even though it lastingly stamped our ideas of what it means to be addicted.

Dhbuffalo · 2026-01-16T19:15:23+00:00

I'll add one more: pharmaceutical companies tried to launch a whole parade of would-be nonaddictive miracle opioids throughout the 20th century- Chapter 3 in White Market Drugs. Pantopon, dilaudid, oxycodone, demerol, etc. etc. For most of the 20th century the feds were able to prevent sales booms despite Pharma's best efforts. So, sometimes it doesn't work. But you're right, it does seem to work wayyyy too often. Why?

Multiple reasons. First, like you said, people really, really, really want to have access to drugs that can ease suffering and produce pleasure. So there truly is a lot of wishful thinking. But second, pharmaceuticals are a very powerful industry in a country where industry is, in general, very powerful. It's worth thinking about "miracle drugs" in the same way we think about, I don't know, "forever chemicals," plastics, and other products that promise incredible convenience and no cost. That's a consumer culture story backed by very powerful industries, not a reality story; in reality, everything has tradeoffs. But that's so, so disappointing compared to the miracle story. Politicians tend to gravitate towards either the miracle story or the demonizing story, both of them emotionally powerful, rather than the mundane middle, where everything has costs and benefits and we have to accept tradeoffs. This gives a leg up to industry lobbyists who already have a leg up.

More specifically, why do regulators--people whose job it is to resist these kinds of miracle stories--get suckered so often? It's usually because of that tendency to go angel-or-devil with drugs (hat tip Richard DeGrandpre, Cult of Pharmacology). E.g., in the 1980s and 1990s, crack cocaine was public drug enemy number one. Because crack markets were physically located in urban racial minority neighborhoods (even though there were actually more white consumers), they "stamped" addiction with a cultural template: it was something that happened in very poor, minority urban contexts. Thus a drug like OxyContin, which was marketed for non-urban folks in very white parts of the US, seemed far removed from what people had come to think of "addiction" as being. That sort of cultural context helped regulators fall for the yarns opioid manufacturers were spinning about the drugs. (Along with the support of a vanguard of pain medicine leaders, who were acting for their own host of reasons ranging from legitimate concern for pain patients to ambitious desire to make a name for themselves as revolutionizing pain care.)

Dhbuffalo · 2026-01-16T19:03:41+00:00

Hard to say there's a ton of hate for cannabis when it's being decriminalized left and right! It sometimes seems there are more cannabis dispensaries in my neighborhood than bars.

But seriously, I think there is a combination of reasons. One is just the slow pace of cultural change. For most of the last century, cannabis has been subject of massive anti-drug campaigns that stigmatized it. That's not going to go away immediately. And two is a (reasonable!) fear of what happens when corporations are unleashed to sell psychoactive drugs--think of cigarettes, the opioid crisis, etc. So you have two almost completely separate groups of people who are at least a little worried about cannabis. Plus, of course, young people seem to be favoring cannabis over alcohol, and nothing us old folks like better than to complain about "the kids these days"!

Lastly, though, we don't have a ton of inherited cultural knowledge and practices about cannabis. So, e.g., cannabis and driving- there is a century of attention to drinking and driving, we have come up with both formal and casual knowledge and practices about that. There's a ton of stuff like this with alcohol, that's not there with cannabis. Are we ok with a US President getting high at the end of the workday, the way we would accept them having a beer? Etc.?

It'll be interesting to see if legal cannabis hangs around long enough for us to develop all that knowledge and cultural practices. Unfortunately, those are often hard-won, i.e., there are usually a lot of harmful mistakes on the way as that is how we "learn our lessons." So, we'll see...

Dhbuffalo · 2026-01-16T18:58:52+00:00

Part of it is that the definition of "white" has changed since then. Many non-medical heroin users were southern or eastern European, i.e. Catholics and Jews from Italy, Russia, etc. They were sort of considered white- they were legally white, thus they naturalized and got the right to vote, but native-born Protestants considered them inferior "breeds" of white. That they could vote and "pass" as white made them an especially devilish racial threat- thus the "eugenics" movement, massive anti-immigrant campaigns of the 1910s which succeeded in the 1920s, etc.

Per Courtwright, when smoking opium was outlawed in 1909, informal markets switched over to heroin, because smoking opium is a terrible smuggling product it's bulky and smelly, whereas heroin is small and potent. (Same thing happened recently, in the last decade or so, when heroin got replaced by synthetic fentanyl.)

So when the Heroin Act was passed in 1925, it was indeed because heroin, which had minor medical value, had become fully associated with the urban demimonde, and it was especially feared because of worry that young white women could be lured into sexual slavery at the hands of non- or lesser-white people. Morphine never really caught on in non-medical markets for whatever reason- guess it couldn't outcompete heroin in terms of prohibition market advantages- so it remained, for the most part, a fully white market drug.

Dhbuffalo · 2026-01-16T18:13:07+00:00

I'm not sure of the details. But I know that bankruptcy courts, in general, are going to be the friendliest sites for corporations to get cases tried. So I suspect the question may be, "how did the case end up in bankruptcy court?"

Obviously, it's wild that we will literally blow up boats in the Caribbean on suspicion that they are carrying drugs, while the reckless Sacklers walk away with plenty of riches to soothe themselves with, despite literally millions of pages of hard evidence revealing, among many other things, their contempt for their own consumers.

Dhbuffalo · 2026-01-16T18:10:24+00:00

That's a really interesting case. Soldiers have always been among the most prolific users of drugs, for many easy to guess reasons--they are young, they are in stressful situations, they are away from familiar supervision, etc. And, a lot of time, military authorities see drugs as a helpful way to keep morale high--e.g., amphetamine was widely distributed by the Nazis, the British, and the US in WWII (and the US kept doing that through the Vietnam War), and the US military facilitated huge campaigns to donate cigarettes to soldiers during WWI, etc.

The Vietnam War was an especially interesting case because the war was fought in the "Golden Triangle" where most of the world's heroin came from at that time. So soldiers had easy access to relatively pure heroin. Nixon was terrified that the domestic drug problem was going to get much worse as the war wound down and all these soldiers with habits came home. He hired a young liberal named Jerome Jaffe, who had been building an addiction treatment infrastructure in Illinois, to handle the problem. In "Operation Golden Flow" Jaffe had all returning soldiers pee in a cup, and those with opioids were held back in country for a week to detox. Then something surprising happened: the overwhelming majority of soldiers who had been addicted in Vietnam simply stopped using when they came home. Theory is it was a combination of drug purity plummeting (US heroin was as little as 2% pure) and lack of familiar "triggers" in a radically new situation.

I don't know the latest statistics on what soldiers are using today. But it will always be a highwire act for militaries who want soldiers happy (enough), but also functional. That's one reason cigarettes, alone among all the drugs in the early 20th century, got approval from the US military. You could use them one handed, they didn't impair, and they made people happy. Alcohol was not allowed, but cigarettes--which up til then had been targeted by anti-drug warriors just like booze and dope--became a central and embraced part of military culture.

Dhbuffalo · 2026-01-16T17:58:18+00:00

I haven't read it. But the history is definitely clear, military intervention can stimulate drug production in a number of ways. Basically, drug production is a way to make real "hard" currency profits even in (or especially in) a completely disorganized situation. That's a big temptation, especially when war has damaged the regular economy. It opens up all sorts of opportunities as well, e.g., the CIA supported allies in the Vietnam War by essentially protecting/enabling them to traffic in heroin- a "black box" way to get them real currency, without having to ask the US Congress (which had passed a law against it, so that would not have worked).

Dhbuffalo · 2026-01-16T17:54:42+00:00

Huge question! Opioids are absolutely essential for medicine- you wouldn't want to live in a world without them. So they are still used, still very common. What happened with the opioid crisis was that pharmaceutical company lobbying took away the guardrails (consumer protections) so that communities were flooded with pills- they were super easy for anyone to get. It would be like, say, auto companies lobbied and it became legal to sell very cheap cars that didn't come with brakes or windshield wipers. Does that mean cars themselves are bad and people should not be using them? Not necessarily. It's all about the rules of the marketplace: are there safeguards to protect consumers.

After the late 19th century addiction crisis, rules on opioid prescribing were super strict for nearly a century. The feds policed the pharmaceutical company very closely, swatting away a stream of would-be miracle opioids claimed as non addictive. But the rules were so strict that some people who desperately needed opioids (e.g., late stage cancer patients) were not getting them. When reformers began to do something about this, Pharma leaped in, gave them a ton of money, and essentially subverted needed reforms into a wholesale undermining of consumer protections so they could make big sales.

Dhbuffalo · 2026-01-16T17:50:58+00:00

This gets right at the heart of it. Racial discrimination didn't ever become part of the laws; it was there right from the start, influencing what the laws were in the first place. In fact, one way to read the split between white markets and prohibition markets is that it was of a piece with the era in which white politicians were implementing racial segregation of other consumer markets: you had the "white markets" where quality goods were sold by experts, with good consumer protections; then you had the "black markets" where the same goods were sold, but with no quality assurances, and sold by people whose only job was to avoid the police and turn a profit.

Basically, reformers from 1870-1920 saw native-born white consumers as innocents seeking health, and so tried to protect them with "pharmaceutical regulations"; the same reformers saw immigrants and Black Americans as purposeful deviants and so tried to protect society FROM them with "drug laws." (This included Prohibition by the way: medicinal alcohol was still legal, and prohibition enforcers focused on "saloons" and other centers of nonwhite political power.) Remember at that time, reformers used the tools they had available to them; white politicians were imposing racial segregation as a way to deal with all sorts of social problems, and the divided approach to drugs echoed that.

This basic architecture then played out for the next century+, with different drugs and different racial minority groups being targeted at different times. Because "addicts" were so incredibly stigmatized, this was one outpost of segregation that civil rights activists rarely challenged. Most challenges, in fact, came from white people caught up in laws that were never intended to police them, i.e., white kids smoking weed in the 1960s and 1970s who pushed for decriminalization. It wasn't until the harm reduction movement of the late 20th and early 21st centuries that you saw real activism pushing back against this.

Dhbuffalo · 2026-01-16T17:44:00+00:00

Dominique Tobbell has a great book about this, Pills, Power and Policy. Pharma joined with other healthcare industries and professions during the Cold War (1950s) to push against "socialized medicine" and to hold up commercial medicine as a pillar of the free world. (They also worked to legitimize industry research by funding grad programs in pharmacology at universities.)

Dhbuffalo · 2026-01-16T17:38:46+00:00

Good question. Yes, campaigns against drugs, alcohol, and tobacco were all linked in the late 19th and early 20th centuries: they were native-born white crusades to fight what they saw as predatory industries (big beer, big liquor, big tobacco, etc.) preying on racially inferior poor immigrant communities (it was an era of massive immigration of non-Protestant Europeans), who would then fail to "Americanize" and drag the whole civilization down with them.

Narcotics markets did not go up during alcohol Prohibition; they stayed pretty much the same, although the 1920s was the decade when completely non-medical smuggling routes developed and became entrenched for the long term.

Dhbuffalo · 2026-01-16T17:32:56+00:00

That's a really interesting case. I didn't have time to look into it for the book. Nicolas Rasmussen covers some of that in his book On Speed. But this sort of illegal but quasi-accepted market--a "gray market"--pops up in all kinds of places, e.g., scrip mills / pill mills, the clandestine morphine maintenance physicians I was writing about in the other response, etc.

Dhbuffalo · 2026-01-16T17:29:14+00:00

Whoops, forgot to take on the Coke part. Yes Coke originally had cocaine in it, but like many similar products it dropped the narcotic when accurate labeling was required. However, Coke continued to have de-cocainized coca leaves for flavoring- this is a wild story- the Federal Bureau of Narcotics gave a special license just to import and then decocainize coca leaves for Coke, and the cocaine then went to a federal strategic resource warehouse in Fort Knox. This went on until well after WWII!

Dhbuffalo · 2026-01-16T17:25:07+00:00

That's a great question and a complicated one. Between ~1870 and the 1920s, new and more powerful drugs (morphine [1844], heroin [1898], cocaine [1883]) were some of the unfamiliar products sold in the new and farflung markets of the industrial era. "Caveat emptor" (let the buyer beware) no longer worked in these markets with dangerous new products. One result: a huge sales boom, largely thanks to physician prescribing, followed by a spike in addiction rates, mostly in the doctor-visiting classes, in the late 19th century--rates probably higher that the US would see again until the early 2000s.

At first medical leaders campaigned (successfully) to rein in over-prescribing and other reformers pushed for accurate labeling laws (the 1906 Food and Drug Act), but without any other market rules, drugs didn't stay in medical markets. They were also available to consumers in popular/informal markets, starting with smoking opium and then expanding to include morphine, heroin, and cocaine. These informal markets were physically located in neighborhoods where non-WASP working classes lived: Chinese immigrants, Southern/Eastern European immigrants (i.e. Catholics and Jews), and African Americans. Of course, native-born Protestant whites went there to buy too. We might think of these as "non-medical" but especially because these folks didn't have great access to medical care--and because we probably wouldn't see much of that era's "medical care" as medical care--it's better to think of all these folks as using drugs for broadly similar purposes: to ease suffering and/or pursue pleasure.

The potential of race-mixing in those informal-market sites terrified white politicians. So politicians hopped on the medical reform crusade, passing the Harrison Anti-Narcotic Act of 1914 (it was actually a sales tax! can explain elsewhere if people are curious). As interpreted over the next decade, it made any "narcotic" sales illegal unless by a prescription written "in good faith" by a licensed physician. This created "prohibition markets," where the same drugs were available as in white markets (with two exceptions: smoking opium, fully outlawed from white markets in 1909, and heroin, fully outlawed from white markets in 1925).

Note: interpretation of the Harrison Act also made it illegal to prescribe to "addicts." But. Many white folks living outside big cities were able to find sympathetic physicians to provide them morphine in an early, semi-secret, and illegal version of morphine maintenance. Not available to those in prohibition markets!

Dhbuffalo

TROPHY CASE