There is a long standing history of doctor induced addiction in the US.  “Soldier’s Disease” was well known to doctors in America- ie. Morphinism due to intramuscular injections of IM morphine during the Civil War with subsequent addiction to laudanum, paregoric, opium, and morphine. Physicians of the 1865-1895 era frequently administered IM morphine to those who suffer, especially to women of the 1880s and 1890s for “female disorders”. Many physicians praised the benefits of morphine prescriptions, writing confidently of the drug’s “exaltation of our better mental qualities” and reassuringly that “of danger there is absolutely none”. However by the late 1870s, some physicians began to express concern about morphine over use, and laid the blame at the doors of their colleagues. (Prescribed: Writing, Filling, Using, and Abusing the Prescription in Modern America, Jeremy Green, Elizabeth Watkins JHY Press 2012). In 1888 Virgil Eaton stated “The doctors are to blame for so large a consumption of opium and they are the men who need reforming”.

 

     But opioids did not require a physician’s administration nor a physician’s prescription before 1909 as morphine, opium, and heroin (after 1895) were available in patent medicines, from pharmacies, by prescription, and through the mail. Heroin prominently displaced the words “Non Addictive” on the front of the bottle. Most households in America had a liquid supply of opioids kept at hand in that era and used liberally from very early ages for soothing neonatal colic, teething, and as a treatment for hunger in children when food was unavailable. Physicians used the injections of morphine frequently for many purposes including pain from almost any source and as a common treatment for alcoholism and opium addiction. Physicians initially disconnected the relationship between opium addiction and morphinism in the 1840s, and heroin addiction and morphinism in the 1890s. But by 1900, it had become clear to physicians that the chronic administration of opioids in any form could lead to addiction, whether iatrogenic or recreational or via readily available supplies. However, physicians were divided on whether opioid addiction was a disease or a moral failing. Many of the medical articles written about morphinism (especially in JAMA) from the 1870s onward, were concerned with the treatment of morphinism rather than the causes, with culpability by physicians for the epidemic of opioid addiction receiving nary a mention, partially due to the readily available multiple sources. The amplification of the opioid epidemic of the era by the IM injections of morphine was largely ignored by physicians. The Harrison Act of 1914, was designed to bring the US in line with the 1912 Hague Convention- the first International Opium Agreement that sought to curtail the opium addiction problem, especially in China. The Harrison Act supporters in Congress did not discuss the evils of opium addiction, but discussed the need to change US law to correlate to the international Hague Convention law. The Harrison Act had no moral implications nor was a prohibition act as passed, but was simply a taxation act as a means for controlling and orderly marketing of opium, morphine, heroin, and other drugs in small quantities, over the counter, and in larger quantities by physician’s prescription.   A clause in the act stated, “Nothing contained in this section shall apply to the dispensing or distribution of any of the aforesaid drugs to a patient by a physician, dentist, or veterinary surgeon registered under this Act in the course of his professional practice only”. Registered physicians were required only to keep records of drugs dispensed or prescribed. The Harrison Act was largely unopposed by the medical profession when it was introduced, as this provided a legal framework for physicians to curtail their opioid prescribing and administration, of which they were increasingly concerned, but did not have an exit strategy prior to Harrison to reduce prescribing of opioids to their addicted patients. Ironically, the CDC guideline of 2016 is being used for the same purpose by many physicians in the US.

 

     The medical literature is rife with foreboding titles of the peer reviewed articles from the 1850s through the 1990s regarding opioid addiction – articles that were ignored by the “modern” late 20th century doctor that elected to eschew the sagacity and experiences of physicians past: “1883 JAMA Opium Poisoning”, “1888 JAMA How the Opium Habit is Acquired”, “1888 The Effect of Opium on the Unborn Child”, “1894 Narcomania”, “1895 JAMA Some Questions of Responsibility in Opium and Cocain Inebriety”, “1896 JAMA The Poisoning of a People”, “1896 (JAMA) The Therapeutic Abuse of Opium”, “1906 (JAMA) Protection against dangerous medicines”, “1919 The Treatment of Drug Addiction”, “1919 Narcotic Drug Addiction: A Public Health Problem”, “1921 Report of Committee on Narcotic Drug Addiction”, “1925 On Drug Addiction in the States”, “1926 Morphine and Heroin Addiction”, “1935 Experimental, Clinical, and Legal Aspects of Drug Addiction”, “1945 Congenital morphinism”, “1948 Present status of narcotic addiction with particular reference to medical indications and comparative addiction liability of the newer and older analgesic drugs. “1949 Unilateral prefrontal lobotomy for the relief of intractable pain and termination of narcotic addiction.”, “1951 Control of narcotic addiction”, “1952 Drugs and the doctor; some aspects of addiction in general medicine.”, “1952 Euphomania (addiction to narcotics) in Denmark in the light of 54,000 prescriptions during one month”, “1953 Epidemic of narcotic use among school children in New York City.”, “1953 TOO easy morphine.”, “1953 Drug Addiction and the Art of Medicine”, “1953 Use of electric-convulsive therapy in morphine, meperidine, and related alkaloid addictions.”, “1956 The effects of maternal narcotic addiction on the newborn.”, “1956 Synthetic substances with morphine-like effect; relationship between analgesic action and addiction liability”, “1957 Drug addiction and other considerations in the management of pain with narcotic drugs.”, “1958 Narcotic drug addiction due to the use of anti-cough drugs”, “1959 The effect of maternal narcotic addiction on the newborn infant; review of literature and report of 22 cases.”, “1960 The pharmacology of the opiates and similar addiction-producing drugs.”, “1960 Narcotic addiction treatment and the law.”, “1961 Causes and types of narcotic addiction: a psychosocial view”, “1962 Narcotic antagonists as analgesics.”, “1962 Criminal prescription of narcotics and similar poisonous drugs by a physician—is the state physician obliged to report it?”, “1963 The addiction potential of oxycodone (Percodan).”, “1963 DERELICTIONS OF THE MEDICAL PROFESSION CONCERNING NARCOTIC ADDICTION.”, “1964 NARCOTICS ADDICTION AND THE "AMERICAN SYSTEM"”, “1964 [APROPOS OF A WIDESPREAD WARNING AGAINST THE ABUSE OF ANALGESICS IN SWITZERLAND].”, “1965 DRUG ADDICTION. PHARMACOLOGICAL ASPECTS OF ADDICTION TO MORPHINE AND OTHER DRUGS.”, “1966 Accidental therapeutic drug addiction.”, “1968 Some comments on the opioid addiction process”, “1969 Addiction, psychodelic experimentation and abuse of drugs by the concerned generation.”, “1972 Neuropathologic aspects of drug dependency (narcotic addiction)”, , “1974 Misprescribing analgesics”, “1978 A word of warning: marked increase in hydromorphone (Dilaudid) addiction. “, “1978 Iatrogenic addiction and its treatment. “, “1978 Iatrogenic addiction no less devastating because it’s legal”, “1979 Narcotic analgesics, addiction and endorphins. “, “1980 Treatment of iatrogenic drug dependence in the general hospital”, “1980 Iatrogenic opiate addiction” , “1981 Narcotic addiction in patients with chronic pain. “, “1982 Double prescribing to opioid addicts”, “1984 Curbs on opioid prescribing”, “1984 How the addict gets his prescription”, “1985 Iatrogenic addiction: the problem, its definition and history”, “1985 Medically induced drug addiction”, “1987 Prescription drug abuse and dependence in clinical practice”, “1987 Intraprofessional competitive prescribing for the drug addict”, “1989 Pain management in a drug-oriented society”, “ 1989 Acknowledgement of drug addiction by physicians”, “1990 Chemical dependency and prescription drugs”, “1991 Analgesics and chronic pain: If all you have is a hammer, every disease is a nail”, “1992 Persuading general practitioners to prescribe—good husbandry or a recipe for chaos”, “1992 Drug misuse”, “1995 Painful lessons: opioids, iatrogenic dependence and professional standards”, “1995 Private prescribing of controlled drugs needs closer scrutiny”

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     The advent of the Harrison act in 1914 placed taxation on opioids but also had the effect of limiting physicians treatment of addiction as outpatients. Because of an expansive view of the implications of the Harrison Act adopted by the US Treasury (partly bolstered by the advent of Prohibition) and later narcotic control boards, addicts were no longer viewed as patients by the US government and addiction was not viewed as a disease. Addicts were viewed by the US Government as criminals after the Harrison act was upheld by the US Supreme Court in 1919. The effect of the Harrison Act was much more profound than simply taxation since the Treasury department had their own interpretation of the act that effectively held physicians prescribing opioids for drug maintenance (i.e. Narcotic treatment clinics or chronic pain treatment) were illegally prescribing, and subsequently arrested, prosecuted, and jailed many physicians. This had a chilling effect on addiction treatment as all city and state narcotic clinics closed down, with addicts being sent to the street, and drug violators to federal penitentiaries. Physicians stopped prescribing opioids for addiction and extremely restricted their prescribing for pain for fear of prosecution, although the law allowed prescribing opioids “in the usual course of medical practice”. The formation of the Federal Bureau of Narcotics in 1930 with commissioner Harry Anslinger occupying that office from 1930-1962 continued the cult of fear of physician opioid prescribing, largely keeping physician prescribing in check. This bureau was seminal in pushing the marijuana criminalization act of 1937, with Anslinger remaining a staunch supporter and enforcer of the act throughout his career. The Boggs Act passed in 1951 established mandatory prison sentences for some drug offenses while the 1956 Narcotic Control Act further increased penalties for drug offenses and established the death penalty as punishment for selling heroin to youths. During the era from the 1920s to the early 1960s, only 6% of addiction was due to physician prescribing of opioids. After the retirement of Anslinger in 1962, more reasonable and flexible options became available for the treatment of addiction, with the establishment of methadone outpatient treatment, and the acceptance there was a limited place for opioid prescribing for pain in certain cases. The Comprehensive Drug Abuse Prevention and Control Act of 1970 codified which drugs could be prescribed, and created five Schedules for drugs, grouping them into relative risks of addiction. The subsequent explosion of use of opioids by the mid 1990s had many causes, not the least of which was the permissiveness that came with the Vietnam and post-Vietnam generation regarding drug use, myopic policies of the Federation of State Medical Boards on opioids, state legislatures early adoption of laws that protected physicians from actions of medical boards, JCAHO policies that encouraged opioid use, VA policies that encouraged opioid use, industry manufactured false safety advertising to physicians, physicians excessively exuberant about opioids for the control of pain were teaching other physicians it was ok to prescribe opioids in the 1990s and 2000s and several other governmental and academic papers that encouraged opioid prescribing. However the physicians ultimately were responsible since only they could write the prescriptions, and were like ostriches, burying their head in the sand so not to have to review the century and a half of medical literature that warned about opioid use outcomes.

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"99% of all prescription opioids in the US come from the pen of a physician, dentist, or midlevel practitioner- the problem is overprescribing"

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     Opioid prescribing is directly linked to a number of nefarious behaviors in the chronic pain population that include the terms non-medical use (NMU), aberrant behavior, substance abuse, substance misuse, chemical dependency, and addiction. While there appears to be a spectrum of behaviors that are problematic, they all pose the same legal risk to a physician’s practice if opioids are continued once these behaviors are discovered and the patient has an opioid related drug overdose. These behaviors also can consume a significant amount of time of the physician and their staff in verification of the patient’s stories about the opioids, dealing with the hostility of patients that engage in these behaviors yet believe they are entitled to continued opioid prescribing, and documentation of these behaviors and telephone calls or letters by the patient. In addition, these behaviors may lead to a lifetime of compulsive use of opioids that will be acquired by illegal means if necessary, creating increases in societal crime including theft of property to sell for drugs and exchange of sex for drugs or for money to buy drugs. Addiction and compulsive use of opioids causes increases in the incidence hepatitis B and C transmission/HIV/other STDs.

Addiction and substance abuse from opioids are dose dependent on prescribing. (J Pain. 2015 Feb;16(2):126-34. Non-opioid substance use disorders and opioid dose predict therapeutic opioid addiction.; Pain Med. 2015 May 22. Pharmaceutical Opioid Use and Dependence among People Living with Chronic Pain: Associations Observed within the Pain and Opioids in Treatment (POINT) Cohort.)

The incidence of addiction with opioid use is 8-12% and the incidence of opioid misuse is 21-29% (Pain 2015 Apr;156(4):569-76). Monthly prescription opioid users are 6.9% of the population over 20 (NCHS Data Brief No. 189 Feb 2015 http://www.cdc.gov/nchs/data/databriefs/db189.pdf) equal to 16,283,942 people over age 20. Therefore the number of those addicted to prescription opioids in the US is approximately 1.6 million and the number of opioid misusers is approximately 4.1 million in the US. These numbers are corroborated by the CDC that notes opioid prescribing is related to addiction and dependency on opioids. In 2014, 4.3 million Americans over age 12 engaged in non-medical use of opioid pain relievers in the past month (opioid misuse) and 1.9 million had a pain reliever use disorder (addiction) (Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health or NSDUH, 2014 page 7 and 26) The opioid misuse statistics may actually be 35% worse than reported in self completed surveys such as the NSDUH given misreporting (Appl Health Econ Health Policy. 2015 Apr;13(2):181-92.)

Another study shows that up to ¼ of those receiving prescription opioids long term for non cancer pain in primary care settings struggles with addiction (Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010;105:1776–82.)

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     There is a long list of peer reviewed journal articles describing narcotic dependence, substance abuse and addiction related to prescription opioids: 
* 30% narcotic dependency in inflammatory bowel disease J Clin Gastroenterol. 1988 Jun;10(3):275-8. 
*34% of chronic non-malignant pain patients met the criteria for substance abuse. Clin J Pain. 1997 Jun;13(2):150-5. 
*78% of 127 primary care patients receiving opioids for chronic pain engaged in substance misuse in the past year. (Gen Hosp Psychiatry. 2008 Mar-Apr;30(2):93-9) 
**15% of opioid abuse disorder (DSM IV) in those with chronic disabling occupational spinal disorders (Spine (Phila Pa 1976). 2008 Sep 15;33(20):2219-27) 
**22.5% of opioid using chronic pain patients had 2 of 6 addictive behaviors (Six potential addictive behaviors were identified: daily smoking; high alcohol intake; illicit drug use in the past year; obesity; long-term use of benzodiazepines; and long-term use of benzodiazepine-related drugs.) while 11.5% of the non-opioid users with chronic pain and 8.9% of the individuals without chronic pain had 2 out of 6 behaviors (Pain 2013 Dec;154(12):2677-83) 
23% of primary care patients had a prescription drug use disorder while using controlled substances and 85% had aberrant drug use (Pain Med 2012 Nov;2012 Nov;13(11):1436-43) 
Everyday, over 1,000 people are treated in emergency departments for misusing prescription opioids (Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. Available from URL:http://www.samhsa.gov/data/2k13/DAWN127/sr127-D...)

Opioid abusers had 12 times higher hospital admission rates, 8 times higher annual health care costs, 5 times higher prescription drug costs compared to non-abusers (J Manag Care Pharm. 2005 Jul-Aug;11(6):469-79.) The cost of prescription opioid abuse in 2005, before the explosion of substance abuse associated with these drugs, was 8.6 billion dollars with 53% of this amount due to workplace costs, 30% due to direct healthcare costs, and 17% criminal justice costs (Clin J Pain. 2006 Oct;22(8):667-76.) 
Four in five new heroin users started out misusing prescription painkillers (http://www.asam.org/docs/default-source/advocac...) 
There is a disconnect between the very rapid increase in heroin deaths compared with heroin use in the general population. Heroin deaths in 2010 were approximately 2500 and increased to 10,574 by 2014- a quadrupling of the number of deaths. However in the general population according to the 2014 NSDUH survey, between 2010 and 2014 heroin use changed from 0.2% to 0.3% in the US population over age 12. Even in the 18 to 25 age group, the increase has been from 0.6% to 0.8% (National Survey on Drug Use and Health, 2014 page 11). The reasons for this disconnect are unclear but may be related to the new users of heroin that have converted from prescription opioids that are becoming increasingly difficult to find, more potent heroin acquisition, or heroin laced with other drugs such as fentanyl. The overall use of heroin is relatively stable at approximately 660,000 users per year, yielding a death rate of 1.6% per year. Monthly prescription opioid users are 6.9% of the population over 20 (NCHS Data Brief No. 189 Feb 2015http://www.cdc.gov/nchs/data/databriefs/db189.pdf) equal to 16,283,942 people over age 20. Given the number dying from prescription drug overdose 18,893 with the vast majority over age 20 (all but 264 according to a CDC Wonder Search for 2014), the death rate is 0.11%. This suggests heroin use has 63 times the risk of death as prescription opioid use. 
Risk factors for opioid abuse: a diagnosis of non-opioid substance abuse (OR 2.34), mental health disorders (OR 1.46). Prevalence of mental health disorders in those taking opioids was 45.3% compared with the prevalence of mental health disorders in those not taking opioids 7.6%. (Pain. 2007 Jun;129(3):355-62.) Those with more severe psychiatric disease took opioids longer, had higher SOAPP and COMM scores, had a higher incidence of abnormal urine toxicology screens, and higher scores on DMI. (Clin J Pain. 2007 May;23(4):307-15.)

Regular users of opioids had 14.8 times the rate of problem opioid misuse, 5.5 times the rate of opioid misuse, 4.5 times the rate of non-opioid problem drug use, 1.7 times the rate of non-opioid illicit substance abuse, and 1.9 times the rate of alcohol abuse compared to those not using routinely using opioids. (Pain Med. 2007 Nov-Dec;8(8):647-56.)