Screening for and treating IPV should be a routine part of the practice and training of medicine. We all have the obligation to confront the epidemic of IPV and strive to lessen its impact as one of the most important public health issues of our time.

Videoconferencing-based health interventions such as telemedicine have been shown to help trauma and abuse victims by providing psychological services via telemedicine.

Most interventions are ordered by the criminal justice system and, unless mandatory, have very high dropout rates.

Why they remain in these relationships is complex. Some of the reasons include the following: ++ Fear. Fear for their own safety or for their children. Patients often are not at home when the assault takes place, so it is clear that leaving is no guarantee of safety. Economic. Many IPV victims lack employment skills or experience and would find it very difficult to support themselves and/or their children outside of the relationship. Psychological. Some may find it difficult to leave because of the “psychological dependence” the years of repetitive abuse have created. Survivors are told overtly and covertly that they are “worthless”; some eventually internalize this and come to believe that they are incapable of surviving on their own. Social support—or the lack thereof. Survivors are often encouraged by well-meaning friends and family members to “try to work things out,” or they are advised to stay “for the children’s sake.” Lack of other options. Shelters are often full, friends and family unavailable, and legal counsel not accessible. Not all survivors want the relationship to end, just the violence.

The third barrier to detection of IPV arises from practitioner discomfort.

First, many practitioners lack the appropriate knowledge and training to effectively detect and treat victims of IPV.

Many studies have revealed that physicians and other health care practitioners do a poor job of detecting IPV, with detection rates rarely exceeding 10% for women.

Lack of institutional support is a second important barrier.

There are four pitfalls to avoid when caring for victims of IPV: ++ Do not insist that the patient terminate the relationship, even if you believe that this is the most appropriate action. Only the patient can make that decision. Trying to control the patient’s behavior, albeit subtly, recapitulates the same negative dynamic that is taking place in the abusive relationship. Recommend couple counseling only when the perpetrator acknowledges the problem, wants to change his or her behavior, and both partners want to preserve the relationship. Do not use the word alleged in the medical record. It implies that you do not believe the patient’s story, and you may inadvertently impede his or her ability to bring the case to court. Do not ask what the victim did to bring on the violence.

CASE ILLUSTRATION 3

Finally, understand the IPV reporting requirements in your state. Health practitioners often are required to report to the police all incidents of IPV that result in an injury.

Fourth, the patient must be provided with information and appropriate referrals.

Third, it is imperative that practitioners document clearly and completely when they uncover IPV.

Second, it is essential

First, validate the problem by making a clear statement to the patient that violent behavior is unacceptable and illegal, and that nobody has the right to abuse him or her.

Multiple studies show that screening alone, without intervention, does not improve a woman’s health outcomes. Instead, an empathetic response by the health care provider, coupled with a multicomponent interventional approach, has shown benefit in patients who experience IPV.

Table 40-4.After detection: five tasks to accomplish.

Table 40-3.Screening questions.

The HITS screening instrument is widely used and consists of four questions (“Have you been hit, insulted, threatened, or screamed at?) on a 5-point Likert scale from “never” to “frequently”; it is available in several languages and has been validated for use with men and women.

In fact, for many patients, even in EDs, the presenting complaint is often medical or psychological, rather than a physical injury. For this reason, detection of IPV will increase only if clinicians include it on the differential diagnosis and actively screen for it during the medical encounter.

Injuries at Different Stages of Healing

Behavior that appears to be inappropriate at the time of the physical examination may be a sign of IPV.

Central Pattern of Injury

Multiple Injuries

Inappropriate Behavior

Table 40-2.Physical examination clues to the presence of IPV.

CASE ILLUSTRATION 2

Socioeconomic or Ethnic Status

Although some studies have found that women who are uninsured or on medical assistance are at increased risk of IPV, this is most likely due to selection bias in the studies.

Overbearing Partner

Family History of IPV

HIV and STIs

Substance Use

Depression, Anxiety, And Other Mental Disorders ++

Multiple Somatic Complaints ++

The CDC’s Behavioral Risk Factor Surveillance System (BRFSS) survey highlights the increase in chronic conditions among people who experience IPV. These conditions include diabetes, asthma, arthritis, hypertension, hyperlipidemia, and cardiovascular disease.

Table 40-1.When to screen for IPV.

CASE ILLUSTRATION 1 A 40-year-old nurse presents to the ED with a chief complaint of a headache. She reports having been in a motor vehicle accident 3 days earlier and striking her head on the dashboard. She says that her friends encouraged her to come in, and she is accompanied to the ED (but not the office) by her partner. On physical examination she appears tense and sad, with bilateral, periorbital ecchymoses.

The NIPSVS shows that 29% of men have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetimes. Up to 14% of men report severe physical violence.

In fact, the NIPSVS shows that the highest prevalence of lifetime physical violence, rape, and stalking is among bisexual women (61%).

PV accounts for more than half the murders of women in the United States every year.

In addition, an estimated 19.3% of women and 1.7% of men in the United States reported having been raped, and cross-sectional studies from outpatient primary care clinics and ED settings have found even higher rates in primary care, emergency departments, obstetrics and gynecology clinics, and mental health and addiction practices.

Recent information from the CDC-sponsored National Intimate Partner and Sexual Violence Survey (NIPSVS) found that 37% of women have experienced sexual or physical violence or stalking by an intimate partner in their lifetime, with up to 23% of women and 14% of men reporting severe physical violence by an intimate partner (including acts such as being hit with something hard, being kicked or beaten, or being burned on purpose).

The total annual costs related to IPV are estimated to be between $2 and $7 billion, and the CDC estimates that the lifetime costs are up to $36 trillion, including medical expenditures, lost productivity among victims and perpetrators, criminal justice costs, and property loss or other damage. ++

burnout, which consists of emotional exhaustion (including compassion fatigue and dissociation from feelings in general), depersonalization in relationships (treating oneself, patients, coworkers, and family members as objects), and a perceived clinical ineffectiveness.

A frequent manifestation of burnout is “compassion fatigue,” in which an overload of suffering threatens to run our emotional tank dry and lead to dissociation, characterized by a withdrawal of attention from emotions and somatic sensations as we focus cognitively and visually on complex patient care problems or get absorbed in our “to do” list.

CASE ILLUSTRATION 2 (CONTD.)

CASE ILLUSTRATION 2 (CONTD.)

CASE ILLUSTRATION 2

CASE ILLUSTRATION 1 (CONTD.)

CASE ILLUSTRATION 1

They differ from negligence or malpractice, which require both preventable harm and violation of the standard of practice.

An error may be an act of commission or an act of omission.” An adverse event is an injury due to health care. Errors differ from adverse events because they do not necessarily cause harm.

an error as “the failure of a planned action to be completed as intended (i.e., error of execution), or the use of a wrong plan to achieve an aim (i.e., error of planning)

During this period, LGBT people may become dependent on health care providers and feel uncomfortable disclosing their LGBTQ identities. Because there are varying degrees of disclosure, older individuals may be “out” to themselves and a partner or close friends but no one else beyond that trusted circle.

LGBTQ seniors are more likely to be single and without children compared to heterosexual counterparts and, thus, have inadequate social supports as they age.

CASE ILLUSTRATION 2

As a relationship develops between the patient and the provider, it is appropriate to inquire more deeply about how a patient’s gender identity or sexual practices may impact their health.

Table 17-1.Suggested questions.

Because LGBTQ people may not be identified by their outward appearance, providers need to use questions that avoid bias with all people, not just those they suspect of being LGBTQ.

CASE ILLUSTRATION 1

LGBTQ patients frequently report detrimental experiences with health care providers. Recent studies document implicit bias against sexual minorities among heterosexual health care providers.

Homophobia is defined as an irrational fear of or prejudice against gay men, lesbians, bisexuals, and queer people. Transphobia reflects a similar fear or prejudice against transgender and gender nonconforming individuals.

Gender identity refers to one’s internal sense of self, of being either a man or woman, a combination of the two, neither, or a different gender altogether.

LGBQ people make up anywhere from 1% to 10% of the general population—depending on the source quoted and the sampling method used in the study.

Specific knowledge and skills are essential for the health care provider to ascertain the sexual orientation and gender identity of patients; communicate acceptance and understanding of LGBTQ health needs; screen for conditions amenable to behavioral and biomedical interventions; and provide information and resources specific to the lives of LGBTQ patients.

Assessment and confirmation. As is true for any newly acquired skill, some kind of assessment and confirmation of achievement are important for learning and reinforcement.

Praxis. Clinical skill is not truly learned and known until it is used. Increasing expertise is associated with the development of habits that become second nature.

Table 7-2.Reflective questions.

Practice. Medicine, like music and tennis, must be practiced; the same is true of mindfulness.

Thinking out loud. When facing a challenging clinical situation, it can be useful to describe one’s observations, impressions, or clinical reasoning to a colleague or tutor, or to put them down on paper in the form of a written narrative.

Active engagement. When in learning situations, mindful practice can and should be observed directly.

Asking reflective questions. Reflective questions explore the inner landscape; no one can answer them but clinicians themselves.

Priming. Priming refers to creating the expectation for mindfulness. By observing what they do during clinical practice, clinicians can be more present, curious, and attentive.

Availability. Just as clinicians should make themselves psychologically and physically available to their patients, teachers should carve out time and space in which they are available to observe and discuss students’ progress toward greater self-awareness, whether in a small group setting or individually.

Table 7-1.Group learning experiences that promote mindful practice.

Mindful practice involves cultivating the ability to monitor and modulate one’s own emotional reactivity. Faced with emotionally challenging situations, humans often overreact by blaming (oneself, another clinician, or the patient), whereas others underreact by avoiding, minimizing, or distancing.

Educators, psychologists, and cognitive scientists have called these automatic nonconscious mental processes “unconscious competence,” the “unthought known,” or “preattentive processing.

Mindfulness means being simultaneously attentive to external data as well as to internal data—the clinician’s own thoughts, feelings, and inner states.

CASE ILLUSTRATION 2

Mindful practice involves allowing awareness of our own areas of ignorance, as well as our areas of expertise.

CASE ILLUSTRATION 1

A mindful practitioner can see a situation from several angles at the same time. Mindful practice implies curiosity rather than premature judgment, and presence rather than detachment.

Mindfulness is especially important in the diagnosis and treatment of mental disorders, because there are few other anchors than the clinician’s own perceptions and judgments to assess the severity or pervasiveness of anxiety, depression, or psychosis in a particular patient

Mindful practice refers to clinicians’ capacity for reflection, self-monitoring, and self-awareness during actual clinical practice in order to practice with clarity, insight, expertise, and compassion.

We can replace the current culture of rugged individualism with a culture of teamwork, accountability, and mutual support.

clinicians, administrators, patients, and families need to work together in partnership to redesign our medical institutions, making them more respectful and humane, collaborative, accountable, and responsive to the needs of the people they serve and the people who work within them.

The principle of reciprocity governs much of human interaction. Mutually helpful behavior and camaraderie create a virtuous cycle in which employees thrive and succeed. Reciprocity can also tear an organization apart.

When clinicians feel that the organizational focus on productivity and financial performance is so intensive and unbalanced that they are forced to provide care that they know to be of substandard quality, they experience a moral injury, resulting in symptoms of burnout.

Collective Self-Care

Self-Reflection & Self-Care

Coaching & Negotiation

Communication

Time Management

In contrast to the control model, which attends exclusively to outcomes, this model calls for explicit attention to process, to the quality of communication, and to the values enacted in the way we work together.

In the relational model, we seek to be with and to understand the patient in a number of dimensions simultaneously—biological, experiential, functional, and spiritual.

Through the influence of Western culture in general and medical culture in particular, we often perceive being in control (of diseases, patients, and the health care team) to be the ideal state (Table 6-1).

Table 6-1.A comparison of control- and relationship-based personal philosophies.

Developing a personal philosophy tends to be a subliminal process—a gradual internalization of attitudes and values from family, culture, education, and life experience—making it possible for us to be entirely unaware of our core beliefs as an ideology.

Among our most fundamental needs are those for human connection, meaning, and self-transcendence—experiencing ourselves as part of something larger than we are.

In addition to our universal needs for connection and meaning, we also have very individual neurotic needs—born of pain and conflict—that are intimately related to our medical work.

These darker, neurotic needs are no less legitimate than those less hidden; they, too, are a normal part of life.

The prevalence of burnout in the primary care workforce has been estimated to be as high as 50%

Don, a 38-year-old primary care physician, sighs as he sees Mrs. D.’s name as a last-minute addition to his patient list. It is mid-afternoon on Friday, and he had blocked out the last hour of the day to attend his son’s final softball game of the season. “Of all the days for one of her ‘crying headaches’,” Don mutters to himself, “why today?”

The primary care provider is encouraged to make good use of the three-function model for interviewing and ongoing communications with his or her patient (see Chapter 1). The following key factors should be attended to in the treatment of chronic pain:

CASE ILLUSTRATION 4 Postherpetic Neuralgia

CASE ILLUSTRATION 2 Chronic Intractible Pain: Chronic Low Back Pain

CASE ILLUSTRATION 3 Fibromyalgia

Cognitive-behavioral therapy and other behavioral approaches (see Table 38-2) are often useful therapies independent of the multidisciplinary pain rehabilitation programs and would be reasonable adjuncts for this patient.

it does not need immediate or intensive medical care; it does not need further diagnostic evaluation (because a detailed medical evaluation had already been done); and it does not need further multiple/different medication trials (these have also been tried).

CASE ILLUSTRATION 1 Chronic Headache Pain

Implantable Pumps: Intraspinal infusion of opioids or other medications into the intrathecal area through an implanted pump is available.

Spinal Cord Stimulator: Neurostimulation is provided by an implanted pulse generator through electrodes that are targeted to the spinal cord with the intent of blocking the pain signal.

Ketamine has some evidence for its use in pain management. There is limited evidence for high-CBD medical cannabis in the treatment of neuropathic pain. +++

Because venlafaxine can cause hypertension and induce ECG changes, patients with cardiovascular risk factors should be carefully monitored when starting this medication.

Table 38-7.Pharmacological management of neuropathic pain.

It is essential when taking a patient’s history to listen for descriptions such as burning, shooting, pins and needles, or electricity, and for pain associated with numbness.

Constipation is common at any dose of opioid, and tolerance to this side effect does not develop over time.

Table 38-5.Opioids.

Table 38-4.Acetaminophen,

The NSAIDs, including COX-2 inhibitors, can lead to fluid retention and exacerbations of congestive heart failure and should be used with caution in patients with that condition.

NSAIDs increase the risk of gastrointestinal bleeding by 1.5 times normal.

Acetaminophen and NSAIDs are in many cases the first-line pharmacotherapy for chronic noncancer pain.

Nutrition as a primary intervention to reduce pain, has had growing acceptance both in reducing the inflammatory processes, as well as in improving diet for maximal function.

Interdisciplinary pain rehabilitation programs (IPRPs) utilize the services of a pain physician, pain psychologist, physical and occupational therapist, nurse, biofeedback therapist, and others often employ several healing modalities, including hypnosis, mindfulness, and ACT.

Relaxation and stress management have been shown to be useful in reducing comorbid anxiety and report of pain (see Chapter 35). Hypnosis can also be utilized through imagery and relaxation to focus attention and assist with reduced pain and improved sense of well-being (see Chapter 5).

Mindfulness training is a primary modality for the treatment of chronic pain. Mindfulness is the practice of bringing complete attention to one’s present experience.

Acceptance and commitment therapy is an approach to treating chronic pain that uses mindfulness training as well. It combines mindfulness with cognitive defusion (the process of separating or defusing thoughts and images from emotions and memories).

Biofeedback is a computerized audio and visual feedback system that uses physiologic measures to amplify the individual’s awareness including muscle contraction (through electromyography (EMG), sympathetic arousal, skin temperature change, heart rate variability (HRV), and brain activity (through electroencephalogram [EEG]).

Our analysis and reaction to the sensory experience of pain is called “suffering” and is entirely in our control. The practice of mindfulness allows us to “relax into the pain” and to observe or even alter our reactions to the sensory experience of pain.

Table 38-3.Patient self-help resources.

Table 38-2.Behavioral treatment methods for pain.

CBT and other therapies that have been demonstrated to be effective in the treatment of chronic pain include: Biofeedback Therapy, Hypnosis, Mindfulness Therapy, Acceptance and Commitment Therapy (ACT) and relaxation therapies.

Cognitive behavioral therapy (CBT) has been proven as a primary evidence-based approach in the treatment of chronic pain in multiple randomized controlled studies.

Obtain a description of the pain and the meaning or impact the pain has on the patient’s life and the life of others around the patient. Assess for comorbid psychiatric conditions such as depression and anxiety. Perform a focused physical examination based on pain history. Review or obtain diagnostic studies that might rule in treatable physical pathology. Use communication and empathy skills to discuss pain treatment. Explain rationale for avoiding opioid analgesics for chronic noncancer pain. Provide nonpharmacological alternatives in context of Prochaska’s “stages of change” model. Negotiate goals of treatment as restoring function and quality of life versus only eliminating nociception. Provide relief and comfort through medication and reassurance. Use multiple management modalities. Assess for change in pain behavior and overall function. Reinforce improvement in function and reduced pain (the goals of treatment) and discontinue ineffective treatments that do not achieve these goals.

able 38-1.The three-function model of the medical interview.

An important first step for clinicians is to seek patients’ expectations of treatment before sharing their own approach and philosophy of chronic pain treatment.

The cost of pain in the United States is greater than the combined cost of cancer and diabetes.

Roughly 20% of the patients with acute pain will eventually seek treatment each year for chronic noncancer pain.

The International Association for the Study of Pain (IASP) defines pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

Despite even the best efforts, acute pain evolves into chronic pain in approximately one out of five patients.

The most common treatment for opioid use disorder is buprenorphine.

Continuing to taper patients who are suffering from withdrawal is dangerous and may prompt patients to seek opioids from nonmedical sources.

There are scant empirical data to support specific tapering protocols, largely because patients’ psychological and physiologic responses to tapering vary tremendously.

Table 25-16.Do’s and Don’ts for discussing opioid tapering with patients.

When patients resist tapering, keep the discussion focused on the patient’s goals rather than pain intensity; do not get drawn into a fight about opioid dosages.

It is usually unhelpful to cite risk of overdose and death as the justification for opioid tapering unless the patient has a high absolute overdose risk or has previously expressed concerns about opioid safety.

Table 25-15.Nonopioid treatment categories for chronic pain.

Patients with chronic pain typically need to use multiple treatments simultaneously (each of which has small to moderate effects by itself) to achieve optimal pain control.

Table 25-14.Useful questions for discussing pain treatment goals.

Tolerance to opioids’ analgesic effects develops faster than tolerance to their sedating effects, so patients taking high opioid doses often experience both uncontrolled pain and substantial sedation.

Table 25-13.Common domains for functional pain treatment goals.

Table 25-12.Useful questions for conveying empathy about chronic pain.

The “ask-tell-ask” approach is one simple, effective strategy for eliciting patients’ perspective while also suggesting a potential treatment approach.

Table 25-11.Distinguishing opioid use to maintain function from opioid use to cope with pain-related distress.

On the other hand, patients who are taking opioids primarily to relieve distress or cope with stressful life circumstances tend to be less functional when taking opioids. These patients should be encouraged to use nonopioid strategies, such as SSRIs, cognitive behavioral therapy, and mindfulness exercises instead of opioids.

Table 25-10.Useful questions for eliciting patients’ perspective on pain.

In interviews about patient–clinician communication, patients with chronic pain reported that clinicians often do not seem to take their pain seriously and identified asking detailed questions as an important way that clinicians can demonstrate that they take patients’ pain seriously and care about treating it.

A useful strategy for keeping an open mind about opioids and chronic pain is to identify something unknown about the patient’s beliefs about pain and opioids and then ask about this during the visit. This exercise helps to remind clinicians to consider the patient’s perspective about pain and helps to avoid mistaken assumptions.

Mindfulness refers to clinicians’ capacity for self-awareness and reflection during patient–clinician interactions (see Chapter 7).

Table 25-9.Steps for communicating effectively about opioids and chronic pain.

CASE ILLUSTRATION 1 Mrs. Park is a 58–year-old woman coming to clinic for a routine refill on her pain medications. She takes 60 mg morphine extended-release every 8 hours along with hydrocodone-acetaminophen 10 mg/325 mg for “breakthrough pain.”

For example, while clinicians tend to underestimate pain relative to their patients, they underestimate pain for black patients to a greater degree than for white patients.

Careful monitoring is always appropriate when prescribing opioids; however, only about 1 in 10 patients taking long-term opioids develops opioid use disorder.

Low-risk patients are those taking 50 MME or less who have no other overdose or substance use risk factors.

High-risk patients are those taking greater than 50 MME who have at least one additional major overdose risk factor.

Intermediate-risk patients are those that do not fall into either the high- or low-risk categories; they make up the majority of primary care patients taking opioids for chronic pain.

Table 25-8.Practical approach for classifying patients by overdose risk.

Deviations from agreements should not be used as a pretext for stopping opioids but should instead prompt further discussion and reevaluation of the risks and benefits of continued opioid use.

Currently, there is insufficient evidence to determine whether implementing prescription drug monitoring programs reduce prescription-opioid related overdose rates.

The Current Opioid Misuse Measure (COMM) is a screening tool for patients already taking opioids that has been validated in primary care populations but is too long for routine clinical use.

The most important risk factor for developing opioid use disorder is prior history of opioid use disorder or some other substance use disorder.

A patient who has been taking 180 mg of extended-release morphine for 2 years is at lower overdose risk than a similar patient who escalated to that same dose within 1 year of starting opioids.

Patients getting opioid prescriptions from multiple prescribers or filling prescriptions for multiple pharmacies have increased risk of overdose.

Patients with chronic hypoxemia or impaired lung function due to conditions such as chronic obstructive pulmonary disease (COPD), muscular dystrophy, and pulmonary hypertension are at increased overdose risk due to respiratory depression.

Sensitivity, specificity, and positive likelihood ratio associated with prescribed opioid dose thresholds for predicting fatal opioid overdose.

Thus, clinicians should not focus on prescribed opioid dose to the exclusion of other risks factors when evaluating patients’ overdose risk.

Table 25-6.Major risk factors for opioid-related overdose.

Meperidine and tramadol are both contraindicated in patients taking monoamine oxidase inhibitors (MAOIs) inhibitors and increase the risk of serotonin syndrome in patients taking selective serotonin reuptake inhibitors (SSRIs) such as paroxetine.

Methadone has fallen out of favor for treating chronic pain because it interacts with more drugs than prototypical opioids, is associated with prolonged QT intervals on electrocardiograms, and has metabolites that build up with prolonged use.

Distinguishing uncontrolled pain from opioid withdrawal.

Hyperalgesia manifests as diffuse, generalized pain and an abnormally low pain threshold; patients with hyperalgesia report severe pain with minor trauma or with normal movements during daily activities.

Table 25-4.“Opioid Review of Systems” for clinically important side effects associated with oral opioid consumption or opioid withdrawal.

patients taking higher opioid doses to maintain pain relief or euphoria are thus at heightened risk for inadvertent overdose.

Developing an “Opioid Review of Systems,” such as the one shown in Table 25-4, is a useful way to remember and ask about the full range of opioid-related side effects.

Opioid-naïve patients often describe their first experience with opioids as unpleasant, and bothersome side effects are a major reason that patients elect to discontinue opioids.

Opioids are not recommended to treat pain due to nerve damage or dysfunction, including pain from diabetic neuropathy, fibromyalgia, or sciatica.

Patients who benefit from long-term opioid use typically experience these benefits at low or moderate opioid doses.

The SPACE trial, the first randomized study of opioid use for chronic pain that followed patients for at least 1 year, was published in 2018.

The CDC recommendation to limit opioid prescribing for acute and postoperative pain to 7 days’ supply or less (see Table 25-2) is an effort to prevent patients prescribed opioids for acute pain from becoming long-term opioid users due to automatic refills or clinical inertia. ++

Table 25-3.Relative potency of commonly used opioid analgesics.

Opioids’ potency is measured relative to morphine, and is expressed in morphine milligram equivalents (MME). The conversion factors listed in Table 25-3 are widely accepted approximations based on clinical consensus.

Acute opioid withdrawal is often very uncomfortable but, unlike alcohol or benzodiazepine withdrawal, is not physiologically dangerous.

Illicit fentanyl is extremely potent and much cheaper to manufacture than heroin. It is typically packaged and sold mixed with or disguised as heroin or prescription opioids, and can be fatal to first-time users.

CDC recommendations for prescribing opioids for chronic pain.

In 1996 the American Pain Society launched a successful public health campaign to treat pain as the “Fifth Vital Sign” in order to highlight patients’ ethical right to pain treatment and to encourage the use of opioids to treat chronic pain.

In 1914 the United States passed the Harrison Narcotics Tax Act, the first major federal law to regulate and tax the manufacture and sale of opioids.

Table 25-1.Partial timeline of events related to opioid use in the United States.

Diacetylmorphine, or heroin, was first synthesized in 1874 as part of a search (still ongoing today) for nonaddictive alternatives to morphine.

Morphine is a naturally-occurring component of opium that was isolated in the early nineteenth century and was commercially available in Europe and the United States by the 1820s.