I once carried out a morning clinic where the first two patients both requested opiates but for entirely different reasons. The first patient was an elderly man with bone cancer. He came for a repeat prescription for a concentrated morphine solution to control his pain. I readily gave him what he asked for. The next patient was a young woman who said she was visiting from Glasgow and told me she was recovering from heroin addiction and was on a withdrawal programme there. She told me a story of having had her handbag stolen the previous day with her prescription in it, and needing a replacement. I politely refused. She left with little protest. A visitor from another planet, observing these two consultations, might have been puzzled as to why I was so generous with one person, and so strict with the other. I would have had to explain that, sadly, consultations like the second one are about twenty times as common as the first in inner city practices: the first patient’s request was entirely legitimate, while the second was almost certainly deceitful, and driven by a craving for the drug itself. Almost every GP will prescribe in these circumstances only to patients they know, or at the request of a doctor elsewhere who does.
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 polarised identities 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. Dormandy died recently at the age of eightysix. He was a polymath and linguist who took his basic medical exams three times over – in Rumania, Switzerland and London – each time political circumstances in the 1940s forced him to move. He had previously published books on tuberculosis and art history, as well as being 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.
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 AD 1130 the physician Abulrayan al-Biruni noted that some pilgrims to Mecca sometimes took fatal overdoses. He enumerated the ten 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 eighteenth century, production moved to the Ganges valley, where the plantations were controlled by local potentates until the British colonists took them over. In the twentieth 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 substitutes – 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 fifty 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 to 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.
Dormandy’s unflinching coverage of war and its relation to opium is among the great strengths 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. This was the destruction of China as a viable state in the mid-nineteenth century in two wars fought for the explicit purpose of sustaining profits and tax revenue through opium sales 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 three thousand years of international arts and crafts including ceramics, carpets, textiles, furniture, paintings, gold ingots, bronzes, precious stones and an incomparable library. Its destruction would have been the equivalent of burning down Kensington Palace, the Victoria and Albert Museum, Buckingham Palace, the British Museum and everything in between, as a punitive measure. The sacking of the summer palace, and the massacres that accompanied it to preserve the British opium industry, still affect Chinese perceptions of the west to this day. 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 United States. 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 ten-year conflict in Vietnam, ‘opium and its derivatives were the props of increasingly venal regimes in Saigon’. Working together with Corsican gangsters, the Central Intelligence Agency provided armed back-up for supplies to the native market and the US army. By 1972, eighty-five per cent of soldiers were being offered heroin within a day of arrival, and thirty-seven thousand 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 corpse in a body bag due for repatriation. Dormandy presents a scarcely more reassuring picture of the current state of affairs in Afghanistan, which he characterises as ‘a twenty-first century narco-state’. In the 1970s, the country produced 700 hundred tonnes of opium a year. After the Russian invasion destroyed peacetime agriculture, this rose to 4,600 tonnes. When the Taliban defeated the Russians with US support, this dropped back again to 185 tonnes, but since the US reversed its support for the Taliban and staged its own invasion, it has risen to record levels. In 2010, around eighty per cent of the Afghan police and sixty per cent 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 recent history of opium-fuelled wars. Yet while admitting it was impossible for him to end the book on an upbeat note, he argues that unmitigated gloom would be unjustified, especially as bio-technology is making the opium fields redundant. I hope he is right, but so far it looks unlikely. Currently, opiate use is increasing uncontrollably. Patients who use them to satisfy their craving vastly outnumber those requesting them from physicians for pain relief alone. In the United States and Canada, deaths from overdoses of opiates, whether natural or synthetic, prescribed or otherwise, have become a major epidemic. Dormandy’s hope that ‘the less bad may be allowed to replace the bad’ could take a long time to materialise.