White Market Drugs: Big Pharma and the Hidden History of Addiction in America

By David Herzberg

The contemporary opioid crisis is widely seen as new and unprecedented. Not so. It is merely the latest in a long series of drug crises stretching back over a century. In White Market Drugs, David Herzberg explores these crises and the drugs that fueled them, from Bayer’s Heroin to Purdue’s OxyContin and all the drugs in between: barbiturate “goof balls,” amphetamine “thrill pills,” the “love drug” Quaalude, and more. As Herzberg argues, the vast majority of American experiences with drugs and addiction have taken place within what he calls “white markets,”  where legal drugs called medicines are sold to a largely white clientele.

These markets are widely acknowledged but no one has explained how they became so central to the medical system in a nation famous for its “drug wars”—until now. Drawing from federal, state, industry, and medical archives alongside a wealth of published sources, Herzberg re-connects America’s divided drug history, telling the whole story for the first time. He reveals that the driving question for policymakers has never been how to prohibit the use of addictive drugs, but how to ensure their availability in medical contexts, where profitability often outweighs public safety. Access to white markets was thus a double-edged sword for socially privileged consumers, even as communities of color faced exclusion and punitive drug prohibition. To counter this no-win setup, Herzberg advocates for a consumer protection approach that robustly regulates all drug markets to minimize risks while maintaining safe, reliable access (and treatment) for people with addiction.
Accomplishing this requires rethinking a drug/medicine divide born a century ago that, unlike most policies of that racially segregated era, has somehow survived relatively unscathed into the twenty-first century.

By showing how the twenty-first-century opioid crisis is only the most recent in a long history of similar crises of addiction to pharmaceuticals, Herzberg forces us to rethink our most basic ideas about drug policy and addiction itself—ideas that have been failing us catastrophically for over a century.

• Language: English
• Publisher: University of Chicago Press
• Release date: Oct 23, 2020
• ISBN: 9780226731919

Book preview

White Market Drugs

White Market Drugs

Big Pharma and the Hidden History of Addiction in America

DAVID HERZBERG

The University of Chicago Press

Chicago and London

The University of Chicago Press, Chicago 60637

The University of Chicago Press, Ltd., London

© 2020 by The University of Chicago

All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations in critical articles and reviews. For more information, contact the University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637.

Published 2020

Printed in the United States of America

29 28 27 26 25 24 23 22 21 20    1 2 3 4 5

ISBN-13: 978-0-226-73188-9 (cloth)

ISBN-13: 978-0-226-73191-9 (e-book)

DOI: https://doi.org/10.7208/chicago/9780226731919.001.0001

Library of Congress Cataloging-in-Publication Data

Names: Herzberg, David L. (David Lowell), author.

Title: White market drugs : big pharma and the hidden history of addiction in America / David Herzberg.

Description: Chicago ; London : The University of Chicago Press, 2020. | Includes bibliographical references and index.

Identifiers: LCCN 2020017334 | ISBN 9780226731889 (cloth) | ISBN 9780226731919 (ebook)

Subjects: LCSH: Pharmaceutical policy—United States—History. | Drug control—United States—History. | Narcotics—United States—History. | Drug addiction—United States—History. | Pharmaceutical industry—United States—History.

Classification: LCC RA401.A3 H47 2020 | DDC 362.17/82—dc23

LC record available at https://lccn.loc.gov/2020017334

This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper).

Contents

Introduction

The First Crisis: Opioids, 1870s–1950s

1   Drug wars and white markets

2   Legitimate addicts in the first drug war

3   Preventing blockbuster opioids

The Second Crisis: Sedatives and Stimulants, 1920s–1970s

4   Opioids out, barbiturates in

5   A new crisis and a new response

6   White markets, under control

The Third Crisis: Opioids, Sedatives, and Stimulants, 1990s–2010s

7   White market apocalypse

Conclusion: Learning from the past

Appendix: White market sales and overdose rates, 1870–2015

Acknowledgments

Notes

Index

Introduction

At the turn of the twenty-first century, America faced two seemingly contradictory drug crises. The first began with an unprecedented increase in opioid addiction, especially in rural white areas such as Maine, Appalachia, and parts of the Midwest. Most observers traced this crisis to the aggressive marketing of OxyContin, a long-acting opioid introduced by Purdue Pharma in 1996.¹ The second was an unprecedented increase in incarceration, especially among racial minorities. Most observers agreed that harsh drug sentencing contributed significantly to a crisis so severe, and so racially disparate, that some called it the new Jim Crow.²

There was a brutal irony in this moment of twin social catastrophes: American drug control was too weak to restrain Purdue Pharma, but so strong that it sent countless people to prison. How was it possible for drug laws to have both problems at the same time?

The answer is all too obvious. In early twenty-first-century America, pharmaceuticals were not drugs. Regulating the pharmaceutical industry was seen as separate from controlling drugs, and the crisis of addiction to pharmaceutical opioids was not seen as connected in any way to the crisis of mass incarceration driven in part by drug arrests. Pharmaceuticals and drugs belonged to separate stories, involving different people and different challenges, and calling for different solutions.

This assumed difference provided cultural fuel for one of the most relentlessly sensationalized narratives about the opioid crisis: that addiction had left its traditional home among poor, urban racial minorities and was, for the first time, invading largely white suburbs and small towns, transforming wholesome children into a new breed of addict, supplied by a new breed of dealer.³ The crux of the typical media story on OxyContin was the defilement of white innocence: suburban cheerleader to sex worker, rural honors student to criminal.

To see the opioid crisis as new and unprecedented in this way required a radical act of forgetting. During the last 150 years, small town and suburban white communities have suffered repeated crises of addiction to pharmaceuticals. Indeed, they have been home to far more drug use and addiction than poorer communities with less access to the medical system. These previous crises were no carefully held secret; medical and popular media have been covering them breathlessly for over a century. Yet eerily, year after year, decade after decade, this coverage has recounted the same story of addiction appearing for the first time in places and people where it did not belong.

Why has addiction to pharmaceuticals been so widespread, for so long? How is it possible to continually discover it as if it were something new? What purposes are served by this bizarre, long-running national surprise?

This book answers these questions by remembering the story of what I call white markets: legal and medically approved social institutions within which the vast majority of American experiences with psychoactive drugs and addiction have taken place. White markets, I show, have been home to three major addiction crises in the modern era, far larger than any crises associated with illegal drugs. The first, at the turn of the twentieth century, began with sharp increases in medical sales of opioids and cocaine. The second, from the 1930s to the 1970s, came during a historic boom in sales of pharmaceutical sedatives and stimulants. The third, at the turn of the twenty-first century, grew from dramatic increases in medical use of all three classes of white market drugs—sedatives, stimulants, and opioids. These crises, I argue, all happened for the same reason: a presumption of therapeutic intent that left white markets with insufficient consumer protections. They were also all resolved through a similar set of policies, quite different from (and significantly more effective than) the punitive prohibitions of America’s drug wars. These policies involved a combination of strong regulation of large commercial suppliers and continued provision of safe, reliable drugs to people who needed them, including people who were addicted.

The story of these three crises challenges us to rethink our basic assumptions about drug use, drug addiction, and drug policy. First and foremost, it reminds us that despite its famous drug wars, America has never tried to prohibit the use of addictive drugs. Instead, vast resources have been marshaled to enable and promote use of these drugs in contexts defined as medical. For over a century, providing sedatives, stimulants, and opioids to patients has been one of the single most common therapeutic acts in American medical and pharmacy practice. This has been so consistently true, for so long, that it cannot be written off as an accident or aberration; it has been a primary function of the medical system. The driving question in American drug history has not been how to prohibit use of addictive drugs, but how to define the medical—that is, how to determine who should have access to drugs, under what circumstances.

In theory, at least, the medical is simple to define: use that heals rather than harms. Seemingly simple terms like heal and harm are actually quite complex, however, and have been the subject of intense political conflict. Then too, since white markets have been home to the majority of addiction and drug-related harms, it would make little sense to characterize them as free of harm. Medical status did not confer special protection against addiction to the privileged type of consumer known as patients; it did not immunize pharmaceutical companies against the lure of profit; and it did not prevent physicians and pharmacists from being swept up by unwarranted enthusiasm for new drugs. For much of American history, privileged access to the medical system has meant heightened exposure to addiction and related risks.

Of course, access to white markets was not all bad. Far from it. Even during the three great crises, the majority of white market drug use did not lead to addiction or harm but was unproblematic or even beneficial. It often treated rather than caused addiction. For untold numbers of Americans, sedatives, stimulants, and opioids have been highly desirable tools for easing suffering and pursuing pleasure. In this sense, white markets have indeed been a social privilege, not a century-long conspiracy by Big Pharma or an ongoing therapeutic error by physicians and pharmacists.

The history of white markets thus challenges us to take seriously not just the dire risks but also the irreplaceable benefits of addictive drugs. It also, I argue, provides us with rarely consulted tools for doing so: an alternate history of drug policy driven by the goal of consumer protection rather than free markets or prohibition.

Free markets and prohibition are usually thought of as opposite policies, but in practice they lead to the same end result: poorly regulated markets designed to serve sellers’ profits rather than consumers’ interests. White markets were an attempt to establish a middle ground. They were designed to enable extensive use rather than to quash it, and they did so by protecting consumers from inevitable drug risks such as addiction. True, protections were almost always insufficient—this is why white markets were in crisis for so much of the past 150 years. But the crises also provoked political creativity, leading reformers to build stronger and more effective regulations. Flawed as they were, these white market reforms were the closest approximations of successful drug policy that America has ever seen. Given the disastrous track record of the nation’s drug wars, they are models that merit serious attention.

The mixed track record of white market drug policy highlights an important point that is sometimes forgotten in today’s obsession with neuroscience: the biology of addiction may not change over time, but the extent of addiction, and how harmful addiction is to those who experience it, do change over time—quite a lot. These are fundamentally social issues that wax or wane in response to collective political action. The balance of drug risks and benefits at any given time has been determined more by the social configuration of markets than by the chemical interactions between substances and brains. Political economy, not pharmacology, encourages or prevents individual risks from becoming public health crises.

White market history thus offers an invaluable toolbox of past efforts to regulate rather than to prohibit America’s most dangerous and desirable consumer goods. Yet this history is rarely remembered or consulted during debates around drug policy. Instead it is considered a medical story, relevant only for the supposedly distinctive world of therapeutics. This distinctiveness is overdrawn. The history of white markets reveals that their participants, like most humans, have also been motivated by profit and desire. White market policies, I argue, should be understood as what they actually are: a set of rules designed to maximize the benefits and minimize the harms of addictive drug use. Their failures and admittedly rarer successes offer much-needed history lessons about how (and how not) to approach drug policy more broadly, not just for pharmaceuticals but for all psychoactive drugs.

The people in the markets

Politics is a process, not a result. It is not enough to know the content of good policies; we must also know how they were achieved—or not achieved. White markets are vast and vastly complex social institutions. Many different people have a stake in them for many different reasons. A central goal of this book is to understand those people, their ideas, and their goals, and to trace how their interactions shaped white markets over time.

A particularly important set of characters in the story are four broad, overlapping types of reformers who directly fought to influence drug policy. The first were what historians call therapeutic reformers. These were primarily elite physicians and pharmacists who believed that empowering professional experts—that is, themselves—was the best way to ensure that psychoactive drugs would be used safely.⁴ In contentious alliance with therapeutic reformers were a second group, consumer advocates. This diverse coalition of politicians, journalists, and activists believed that strong government regulation was needed to protect consumers from a profit-hungry pharmaceutical industry.⁵ The third group were moral crusaders. These were law-and-order activists, often native-born white evangelical Protestants, who saw addiction as one of many threats posed by poor, uneducated urban ethnic and racial minorities. They favored punitive policing to protect society from what they considered to be a criminal menace.⁶ Finally, the fourth group, addiction medicalizers, were a specialized strand of therapeutic reformers. They opposed nonmedical drug use but believed that addiction was an illness to be handled by medical experts rather than the criminal justice system.

Through a shifting and often surprising series of coalitions and conflicts, these four types of reformers played central roles in defining and redefining white market drug policy over time. They did not do so alone, however; they interacted dynamically with others also seeking to influence the nature and extent of white markets.

All reformers, for example, had to contend with one of the most powerful actors in the story: the pharmaceutical industry. With endlessly deep pockets, drug companies battled against white market regulations, often deflecting blame for drug harms onto addicts and criminals. Meanwhile they marketed their drugs with aggressive creativity, downplaying addiction and other risks while expanding the definition of medical conditions (or inventing new ones) to justify increased prescribing and sales. No matter how dire the crisis, they did not relinquish profitable sales without a fight. Addictive drugs have inherent dangers, but the drug industry was central in escalating those dangers into public health crises.

A focal point of both reformers and industry were the government regulators tasked with implementing American drug policy: the Food and Drug Administration (FDA) and the Federal Bureau of Narcotics (FBN). A focus on white markets casts these familiar agencies in a new light. Historians typically portray the FDA, for example, as a hard-won and pioneering, yet limited and often outmaneuvered, bulwark of the regulatory state—a marquee, if imperfect, liberal accomplishment.⁷ The FBN and its longtime chief Harry Anslinger, on the other hand, are usually portrayed as an illiberal and malign force, using punitive powers more to racially stigmatize foreigners and the urban poor than to prohibit or even reduce dangerous drug use.⁸ White market history definitely does not debunk this binary opposition. It does, however, complicate it in important ways. Rather than being separate agencies pursuing entirely different missions, the FDA and the FBN appear in this book as twin stewards of the line dividing pharmaceuticals and drugs.

Political reformers, business executives, and government regulators saw themselves as uniquely responsible for the fate of white markets (and American drug policy more generally). These powerful figures, however, actually spent much of their time reacting to, and bemoaning their limited control over, the people they were supposed to be leading: workaday physicians and pharmacists and—perhaps most important—drug consumers. The daily decisions and experiences of these ordinary people drove white market history as much as the more dramatic battles over federal policy.

Physicians and pharmacists, for example, did not always behave as therapeutic reformers wished them to. Most were motivated by the desire to provide patients with comfort and relief, but there was no universal agreement on how to do this. Practices varied widely, from limited or no use of addictive drugs to large scale, overtly commercial pill mills that sold prescriptions to all comers. This variability was possible because of the hard-won professional autonomy physicians and pharmacists enjoyed in America. For the most part they were governed not by distant federal regulators but by state medical and pharmacy boards, composed of their colleagues and often more devoted to professional advocacy than to enforcing the latest federal dictates. To understand white markets, then, means understanding the thinking and decisions of physicians and pharmacists who do not usually appear in the history books except, perhaps, as maddening problems to be fixed by therapeutic reformers.

Finally, the most important and, I believe, misunderstood group of all: drug consumers. They are the ones in whose name all the other people claimed to be acting, and they are the ones whose experiences are the ultimate arbiter of success or failure in policy and practices. Yet they are rarely cast as central figures in histories of pharmaceuticals or drugs; they appear instead as ciphers—as passive pawns of the drug industry or of their own misguided desire for easy solutions to life’s problems.⁹

Consumers are not always central to this book either. Often the story veers far from their experiences and focuses on more powerful figures who did not see themselves, or at least did not portray themselves, as drug consumers. But when consumers do enter the story—and even when they remain at its edges, invoked as justifications by others—they do so not as ciphers but as people with their own lives and agendas, pursuing relief and pleasure as best they could with the information and markets available to them. More often than not, they got what they were looking for. The great majority of white market drug use, after all, did not lead to addiction or death. To desire and to use drugs under such circumstances was not foolish or aberrant; it did not require having been tricked by an evil industry or misled by physicians. White markets thrived, in part, because of the perfectly understandable, human decisions of countless consumers.

To be respectful of consumers, however, also means acknowledging the very real risks they faced. Using addictive drugs can be dangerous, and drug markets have often been set up in such a way as to magnify those dangers unnecessarily. Reformers, drug companies, physicians, and federal regulators may have claimed to be acting on behalf of consumers, but their understanding of who consumers were and what they needed was strongly colored by self-interest. White markets were designed to serve the needs of these powerful groups as well as—perhaps more than—the agendas of consumers. One result was sales that careened out of control thanks to dangerous but hyper-marketed wonder drugs. Another result was the opposite: the exclusion of many consumers, especially those with addiction, from accessing white markets at all. In pursuing pharmaceutical relief and pleasure, consumers had to contend not just with inherent drug risks but with the asymmetries of power and knowledge within (and outside of) white markets.

To write respectfully about drug consumers means writing with care and respect about addiction. This is not an easy task. Take the word addiction itself: over the course of the twentieth century, it has become so stigmatized, so packed with moral associations, that it seems almost impossible to use safely. For good reason, many thoughtful observers urge us to use different terms that better emphasize the humanity of people who use drugs. While I fully agree with their goals, I have chosen not to do so in this book. This requires an explanation.

Two main strategies are used for replacing or revising the term addiction. One is to adopt a medical term such as substance use disorder, which highlights addiction’s status as an illness like other illnesses, deserving of sympathy and care rather than judgment and punishment. These are worthy goals. Yet as a historian, I resist using this term because it casts addiction as a timeless, unchanging individual condition rather than as an experience that has changed significantly over time in response to social, political, and cultural factors. It also obscures the political struggles that produce diagnostic categories and the medical logic behind them. In a book devoted to uncovering and understanding just such political struggles, it does not make sense to endorse a particular era’s medical model of addiction—even if that era is my own.

The second strategy is to distinguish dependence from addiction.¹⁰ Dependence refers to a state of physical adaptation in which a drug is required for normal functioning, whereas addiction refers to compulsive use despite negative consequences. The goal of making this distinction is to acknowledge healthy, functional, long-term drug consumers and to protect them from the stigma and policing associated with addiction. Drawing these kinds of distinction can be a risky endeavor for a historian, however. Since the 1870s, safe drug use—dependence rather than addiction—has been challenging for the socially marginalized consumers forced to navigate unregulated, unreliable, and punitively policed informal markets. Dependence has been far easier to achieve for white market consumers with access to a stable, regulated supply. In other words, historically, dependence has not been an inherent quality of a person’s relationship to drugs, but a contextual quality determined at least partly by the social circumstances of purchase and use. Terms like dependence (and earlier concepts such as habituation) have mostly been used to obscure this fact—to dignify and legally protect the drug use of privileged people in explicit contrast to the drug use of marginalized people. I am already reluctant to act as arbiter of who was truly addicted and who was simply dependent; the political implications of doing so make me even warier.

In the end, I found no way to avoid or transcend the politics attached to addiction, especially since those politics are the subject of this book. There are, however, ways to minimize the harms. Insofar as possible, I use addiction to refer to the broad phenomenon—as a risk associated with certain drugs or as a public health phenomenon—rather than applying it to particular people. Instead of emphasizing differences between people with dependence and people with addiction, I emphasize differences between consumers with access to more or less safe drug markets. This acknowledges both the gravity of addiction and the possibility of safe long-term drug use. It also emphasizes that drug consumers’ safety has been determined as much by social and political forces as by consumers’ own inherent qualities.

Thinking past the medicine-drug divide

White markets are an open secret of American history, widely acknowledged but rarely examined in depth. This is, in part, because they fall into a scholarly gap between historians who study medicines and historians who study drugs. These are different people, who belong to different scholarly societies, each with their own journals and conferences, and who organize their research around their own distinctive questions. Addictive medicines sit directly in the gap between these groups and fit only awkwardly into either. Not all historians respect this boundary between medicines and drugs; a number of excellent works tell key parts of the story.¹¹ Yet much of the story has not been told. Pharmaceutical opioids do not yet have their historian, for example, and despite good biographies of individual classes of drugs, the broader significance of white markets as a whole has not been explored.

From the vantage point of white markets, medicines and drugs appear not as separate things but as parts of a single, complex whole. America has not really had one set of pharmaceutical regulations and another set of drug controls; instead, it has had a single, divided regulatory system that unequally governs access to psychoactive substances. This system was built in the wake of the first white market crisis in the late nineteenth century and was consolidated with the establishment of the FDA and the FBN in the early twentieth century. Since then their stories have marched together in lock step, with major developments on one side nearly always echoed by major developments on the other.¹² This is because the dividing line between medicines and drugs is not a premise but a product of their history, continually renewed and renegotiated. Many drugs, and many types of drug use, have been dragged back and forth across the line—or maybe the dividing line has been dragged back and forth across them. How the line has been drawn at any given point was a social construction—the product of political struggle—but one with real and sometimes life-or-death consequences for consumers both within and outside of white markets.

A central argument of this book is that, most of the time, the division between medicines and drugs has not been effective. It has been an obstacle rather than an aid in protecting the public health. The presumption of therapeutic intent, fiercely promoted by drug companies and the health professions, has protected white markets from the robust regulation needed for such addictive, dangerous, and profitable products. The result has been a boom-bust sales cycle accompanied by a series of devastating public health crises. Meanwhile, the presumption that all nonmedical drug use is illegitimate and harmful has encouraged a long-running punitive anti-drug war with similarly devastating consequences on communities already hard hit by social inequality and, often, by the harms associated with illegal and thus unregulated drug sales. The twenty-first century’s twin crises are just the most recent, severe manifestation of this recurring problem with America’s divided approach to drugs and addiction. To repair and prevent this destructive cycle, I argue, requires knowing and then transcending the history that has built it. I hope this book can be part of that project.

The First Crisis

Opioids, 1870s–1950s

1

Drug wars and white markets

The distinction between medicines and drugs is central to the way Americans think about, regulate, sell, and use psychoactive substances. Both law and custom are designed to promote access to medicines while prohibiting use of drugs. This binary mission is so basic, so fundamental, that it seems obvious.

Yet as countless critics have pointed out, this seemingly obvious mission does not withstand even casual scrutiny. For one thing, drugs and medicines are very nearly the same substances. Heroin, the drug, differs little from opioid medicines; amphetamine, the drug, is the main ingredient of many medicines used to treat attention deficit hyperactivity disorder; and so forth. Nor does it help to shift from pharmacology to context—to define medicines as substances used in treatment of an illness and drugs as substances used in the absence of illness. The types of suffering considered to be illnesses have changed dramatically over time and are also contested at any moment. In practice, the question ultimately comes down to whether a person’s suffering receives a diagnosis—a decision fraught with social, cultural, economic, and political influences. Unsurprisingly, such decisions do not map neatly onto health outcomes. Addictive medicines help ease suffering, true, but they also cause significant harm; fatal overdose of medicines causes many deaths. Meanwhile, addictive drugs cause harm, but only for a (very visible) minority of consumers, and virtually no one asks whether there are also benefits to their nonmedical use—a seemingly crucial area of inquiry if health were indeed the crux of the question.

The distinction between medicines and drugs does not simply reflect reality. It is a human accomplishment, built and rebuilt at particular times and in particular circumstances. Its configuration at any historical moment has resulted from purposeful political action, from conflict, collaborations, and compromises, all in response to now-forgotten challenges and crises. This is why the elegant conceptual simplicity of the medicine-drug divide does not easily map onto any similarly elegant or simple divide in lived experiences. The binary simplicity is achieved, not found. It is a call for more questions, not an answer.

For a historian, the most important question is also the most obvious: if the medicine-drug divide is not a simple reflection of reality, where did it come from? Who built it, why, and how has it been maintained despite its many contradictions?

An opioid crisis in industrializing America

The medicine-drug divide was born as the solution to a crisis. It was the late nineteenth century, an era of industrialization when advances in manufacturing, transportation, and corporate organization led to rapid increases in the production and circulation of a wide range of commodities and consumer goods. Among these commodities and consumer goods were derivatives of the opium poppy and the coca plant. These derivatives were stronger and purer than ever thanks to the isolation of active principles like morphine (from opium) and cocaine (from coca), and new inventions such as the hypodermic syringe. Consumption of these stronger drugs rose rapidly: opioid use more than tripled from 1870 to the mid-1890s, and cocaine use jumped by nearly tenfold in the decade after its introduction in 1883.¹ This wild growth was possible because of a relative lack of state regulation. Drug consumers, like consumers of other goods, faced a bewildering variety of new and often dangerous products. One result was a sharp increase in a distinctive and disturbing pattern of harmful, compulsive use that eventually came to be identified as addiction. Fearful authorities declared an epidemic and implemented a variety of market reforms to deal with it. The most important of these reforms was the medicine-drug divide.

The idea of distinguishing between medicines and drugs did not come out of nowhere. It was built out of a range of informal existing practices that already structured opioid and cocaine markets.² The largest market for opioids involved morphine sold by physicians and pharmacists. Physicians had few ways to ease pain (physical or psychological) during an era when suffering of all types was a near-universal aspect of life. Aside from the devastating impact of the Civil War, workplace injuries, dental problems, and contagious illnesses were common.³ Faced with all this suffering, physicians found St. Morphine indispensable. The US Dispensatory, an official almanac of pharmaceutical preparations and their uses, noted as early as 1858 that opiates were "more frequently prescribed than perhaps any other article of the materia medica, useful in all cases where the object is to relieve pain, quiet restlessness, promote sleep, or allay nervous irritation in any shape.⁴ Physicians reported prescribing opiates for neuralgia, headache, female complaints, respiratory disorders, diarrhea, syphilis, rheumatism, insomnia, anxiety, overwork, masturbation, photophobia, nymphomania, and violent hiccough.⁵ By 1870, a physician observed, morphine injections had reached the height of fashion."⁶ Cocaine expanded from its initial use as a surgical anesthetic to wide application as a treatment for ubiquitous nervous diseases and hay fever.⁷

These medical markets were not equally accessible to all Americans. They mostly served what we might call the doctor-visiting classes: people who were white, native born, Protestant, middle aged, and middle class.⁸ Women were the primary consumers of morphine, and men, especially professional men, were the primary consumers of cocaine.⁹

People with less access to physicians also suffered, and also desired the relief and pleasure that drugs could bring. They too could purchase opioids and cocaine, but through smaller, informal markets outside of medical channels. These informal markets were typically located in poorer, racially mixed urban neighborhoods where municipal authorities segregated the trade in other disapproved goods and services such as sex work, gambling, and alcohol. Drug consumers in these so-called vice districts tended to be poorer and more racially diverse than medical market consumers, although their ranks also included many adventurous middle-class whites.¹⁰

Informal markets for smoking opium grew from complex origins to become particularly important by the late nineteenth century. In the midcentury Opium Wars, Britain, unhappy about a trade imbalance with China, had forced China to allow imports of opium from British colonial India. Unrestricted imports led to a dramatic expansion of opium smoking in China, including among laborers, whose global diaspora helped spread the practice. By the late nineteenth century, a backlash had developed against Chinese laborers, with many political and cultural figures in the West characterizing them as dirty, criminal, and unsuitable for citizenship. In the United States, Chinese workers found themselves segregated into or near urban vice districts. This spatial arrangement was important because, unlike medical opioid use (but similar to Euro-American alcohol consumption), opium smoking was typically social. Consumers used the drug together in the public or quasi-public businesses where they purchased it. Informal markets for smoking opium, in other words, required physical spaces as well as customers. In the United States, those spaces tended to be in or near the urban neighborhoods where Chinese immigrants lived.

Despite their differences, both medical and informal drug markets became hazardous in the late nineteenth century for the same reason: dramatic commercial growth that outpaced consumers’ traditional strategies for recognizing and navigating risks. In both markets, more powerful drugs had suddenly become more easily and more cheaply available. This was not a development unique to drugs; industrialization brought hosts of new products manufactured and sold by distant, unfamiliar concerns whose risks consumers could no longer reliably assess through the era’s traditional mechanisms of contract law (caveat emptor or let the buyer beware).¹¹ Drug addiction and fatal overdoses were no more shocking than, say, babies starved to death on swill milk or women disfigured by toxic cosmetics.¹² And in addition to their shared dangers, medical and informal markets overlapped significantly: many drugs sold informally had been purchased at less reputable drugstores, and drug consumers (especially if addicted) moved between the two markets as opportunities or needs arose.¹³

Authorities at the turn of the twentieth century, however, did not recognize an underlying unity to the crisis. Instead they believed they faced two fundamentally different problems calling for very different solutions. Opium smoking and other informal-market drug use attracted the attention and zeal of moral crusaders and anti-immigrant activists, who incorporated addiction into their broader campaign to govern urban vices, especially by policing white women’s sexuality. Morphine and other medical-market drugs, on the other hand, were tackled by a slowly emerging coalition of consumer advocates and therapeutic reformers who saw addiction as one more example of the need to protect the public by regulating commerce. Together, these two campaigns built the legal and cultural architecture of the medicine-drug divide.

Opium smoking and racialized vice: Building the moral state

Most nineteenth-century Americans saw opium smoking as a distinctively Chinese practice, linked to supposed Oriental qualities such as irrationality, weakness, and emasculation.¹⁴ There is something in the very character of those vast Asiatic populations, ran a typical newspaper account in 1866, with their corrupt and effeminate manners, and their decided tastes for negative enjoyments and a dreamy and contemplative life, which seems to draw them peculiarly toward the stimulus supplied by opium.¹⁵ There was a dark irony to this belief: it blamed the Chinese for a practice driven by British profit seeking and Western hunger for cheap, exploitable labor. But it made perfect sense to nativists who already saw Chinese laborers as a threat to be closely policed and excluded from full citizenship or even barred from immigrating altogether. It thus circulated widely in Europe and America through elite texts such as Thomas de Quincey’s 1821 classic Confessions of an English Opium Eater and in popular media such as the newspaper quoted above.¹⁶

As America’s Chinese immigrant population grew, nativists found so-called opium dens a perfect focal point for their campaign to cast the Chinese as an immoral and unsanitary infestation.¹⁷ In truth, informal markets for smoking opium served a variety of urban consumers. Nativists, however, described the vile, pernicious dens of debauchery as uniquely Chinese—an inevitable manifestation of innate Oriental qualities.¹⁸ As the editors of the Journal of the American Medical Association warned, wherever the Chinese go . . . the curse of opium smoking goes with them. It is a phase of the ‘yellow peril’ that we may have to meet nearer our homes than we have anticipated.¹⁹ A journalist writing for the well-regarded national literary magazine Scribner’s Monthly put it more directly: Just now, he wrote after describing a den visit, we were practically in China.²⁰

Central to the popular appeal of opium den scare stories was their focus on the supposed sexual vulnerability of white women to the lure of opium.²¹ The New York Times, for example, regularly reported on opium den raids in which pretty or fashionable young women were found entwined with Chinese lovers.²² In How the Other Half Lives, influential photojournalist Jacob Riis described the wives of Chinatown as all white girls hardly yet grown to womanhood, worshipping nothing save the pipe that has enslaved them body and soul.²³

As a social problem, then, smoking opium did not stand on its own; instead, it was understood as one aspect of a multifarious racial threat posed by Chinese immigrants, symbolized by the sexual enslavement of white women. So when reformers took action, they did not campaign against smoking opium itself. Rather, they banned opium dens. The first such bans were passed in California: in San Francisco in 1875 and statewide in 1881.²⁴ Chicago’s 1881 ban was typical. It made it illegal to "keep or maintain or become an inmate