Two horrendous episodes of human poisoning with contaminated illicitly marketed drugs have been widely discussed in both newspaper and medical journal reports in toxicocentric language. Such discussion neglects the social and legislative context of the reigning prohibition during which the poisoning occurred, and contributes to the possibility that such poisonings will occur again. Using the 1930 episode of poisoning with triorthocresylphosphate (TOCP)-contaminated alcohol and the 1990's fentanylisomer substitution for heroin, the character of prohibition and its toxic consequences can be illuminated.
Fentanyl is one of a group of phenylpiperidine compounds originally developed as anti-cholinergic drugs, which possess prominent analgesic properties. These compounds, including the most widely used one, meperidine, do not resemble morphine chemically and cause some effects in humans not shared by morphine, however they do cause sedation and analgesia by acting at morphine receptorsl and are used as strong analgesics and anesthetics. One has been marketed recently in a transdermal patch to treat chronic pain. Many fentanyl-like compounds have been synthesized and all are highly potent; that is, they provoke morphine-like effects in very small doses. They may cause analgesia, drowsiness, respiratory depression and even death in the non-tolerant user, in doses under 1.0 mgm.
In the late 1970's deaths occurred in heroin self-injectors in the Western United States who had purchased "China White", reputedly a synthetic heroin. Analyses showed congeners of fentanyl which had been synthesized and marketed illicitly. Most of the illicit products were 3-methyl fentanyl (TMF) or alphamethyl fentanyl (AMF).2 The fentanyl-like drugs do not deliver more opioid effect on injection. However the fentanyl-like drugs deliver euphoria analgesia and respiratory depression in a very small dose. If users have not developed tolerance from frequent prior use they may be at high risk after injecting a very small amount of dissolved powder which contains fentanyl.
The illicit synthesis and marketing of fentanyl products ultimately caused over 100 West Coast overdose deaths by 1986.3 An ironic story emerged in subsequent patterns of Eastern United States poisoning. Just as The New York Times and other Eastern papers announced the deaths of heroin injectors in New York, New Haven and Newark, an article appeared in the Journal of the American Medical Association reporting deaths in Pittsburgh, Pennsylvania and warning that fentanyl congeners had spread to the East.4 Who was being warned? Clearly not the users of heroin; obviously the article was to alert toxicologists and medical examiners.
Newspaper accounts of the NYC deaths prominently featured a narrative text that is largely mythical, although like most myths it may actually have occurred at some time. When the deaths, which were caused by TMF, attracted attention many people told newspaper reporters that junkies hearing of the overdose deaths immediately asked where they get some of the drug.5 The popular musician John Phillips, who appeared frequently on television testifying as a recovering addict, claimed that he tried to shake awake a dying junkie acquaintance to ask that same question. This story is told frequently with such relish and commitment that the teller apparently believes it conveys a general truth about drug injectors: that they are so lustful for drug effect that they will take unconscionable risks and come to harm no matter what is done for them. Tellers of junkie tales wish to convey their belief that junkies are essentially different from other humans.
In March of 1930, American newspapers began to report a strange epidemic of neurological impairment with profound weakness of the legs and arms.6 From the first reports, city health officials and physicians associated the illness with the drinking of a popular illegal Prohibition beverage, an alcohol-based tincture of Jamaica ginger. This product had been sold in the United States since the mid-19th century as a remedy for digestive problems, a treatment for mild upper respiratoly infections and a promoter of menstrual flow. A physician in Eastern Tennessee denied that his affliction was caused by drinking this concoction and believed he contracted an infectious process from his patients. A dozen women from a bridge club, all paralyzed, denied that anyone had added ginger to the punch bowl. Despite these occasional denials the illness was so connected to the Jamaica ginger extract that the characteristic gait of the partially paralyzed walker was labeled "The Jake Walk" and the illness "The Jake Leg".
An alcohol-based extract of powdered ginger root or a partially dried resinous extract of ginger had been sold as a remedy in the United States since the 1860's. To dissolve ginger in alcohol demands an alcohol concentration exceeding 70 percent. The traffic in "Jake" was greatest in Southern states and counties where local option laws had often established alcohol prohibition before 1920. When Federal Prohibition began, the traffic in ginger extract grew so quickly that official recognition followed. Legitimate medicinal solutions of ginger were prepared to constitute a fluid extract. These had to contain 5 grams of ginger (as the powder or resin) for every milliliter of alcohol. This preparation was opaque, thick and highly irritating to drink. Legitimate users were instructed to add a few drops of this product to water before drinking. When the Food and Drug Division of the U.S. Department of Agriculture began to seize ginger extract after March of 1930, they obtained some legitimate extract shipped by companies including Smith, Kline and French, Merck and Upjohn. However the volume of legitimate material was much less than that of the Jake.
The Jake was prepared by adding a small amount of ginger to concentrated alcohol (70-80 percent) producing a potable beverage. Sellers of Jake mislabeled their product to indicate that the contents were prepared as the official fluid extract described by the United States Pharmacopeia (U.S.P). Jake entrepreneurs added a number of adulterants to the product. Glycine, herbs, molasses, and castor oil all were used. The adulterant had to be rniscible with ginger, soluble in alcohol, and preferably odorless and tasteless. Most importantly, the adulterant had to be non-volatile. If the Jake were boiled to dryness, the solid residue would not weigh enough to meet the requirements of a 5gm/lml fluid extract.
After 1920, the market for illicit Jake expanded enormously. Most manufacture occurred in the Northeast. From there, material was often shipped in bulk (usually by rail) to cities of the Southern rim (Cincinnati, Oklahoma City, Nashville, Lexington, Kansas City, etc.). There patent medicine distributors would transfer the beverage to 2-ounce bottles and label it with a variety of names. More than 10 poisoned brand names were seized in Cincinnati alone.7
Late in January 1930, Harry Gross of the Hub Specialty Company of Boston Massachusetts decided to alter the composition of the Jake made at his company. With advice from a Boston chemist, he purchased an ingredient of paint and varnish which contained significant amounts of triorthocresylphosphate (TOCP). This product, still widely employed industrially, met all the criteria of a good adulterant described above. Gross asked the supplier if the material were toxic and was assured it was not. According to his employees, Gross mixed the new Jake himself. Then, Hub shipped the altered beverage all over the United States. Although Southern states were hardest hit, men (and a few women) were paralyzed from Maine to California. Conservative estimates place the numbers of victims at 50,000 although those writing in the late 1930's believed a proper estimate to be 100,000. According to one FDA report, Gross purchased enough TOCP to manufacture 500,000 2-ounce bottles of Jake.8
TOCP bonds to cells in the spinal cord of certain species, producing serious toxicity and cell death. A motor weakness follows, chiefly affecting the legs, which in time become spastic. The Jake victims did not die, but neither did they wholly recover. Ten of eleven victims I saw in 1977 could walk, if at all, only with the aid of canes, crutches or other support.9
These two toxicological events, separated by 60 years are similar in many ways. People who wished to consume certain psychoactive substances had to purchase them illegally. The products were contaminated or misrepresented by illicit marketers in such a way that they were highly poisonous or toxic, beyond the intoxicating effect that the purchasers desired. These events, of great interest to pharmacologists and toxicologists, have been ignored by policy makers. Sadly, there is no lack of poisonings involving other industrial or environmental toxins such as mercury, lead, dioxin or leptophos, a modern pesticide whose effects on humans mimic those of TOCP. 10
The two episodes involving the unknowing self-administration of contaminants illustrate most importantly the impact of drug policy and of prohibition. Citizens continue to accept that government should investigate, indict and imprison other chizens for the essentially universal desire to ingest chemicals which alter mood, consciousness or behavior. Rather than leaving the choice of possessing and ingesting such chemicals to those who desire them (despite potential dangers and consequences), the governments of the world have embarked on a policy of "prohibiting" them. The Jake and China White episodes illustrate that the biggest problem is not pharmacology, but policy.
Richard Cowan has defined the inevitable increase in potency of banned substances, the iron rule of prohibition.1l Perhaps the most simple explanation for potency increase is the need for concealment. Smugglers can more easily hide whiskey than beer, heroin than opium and smokable cocaine ("crack") better than cocaine powder and beverage cocaine. Potency also increases profitability by facilitating the delivery of more saleable doses in a concealed box, a swallowed condom or a stuffed doll. A 32 ounce bottle of 40 percent (80 proof) whiskey contains approximately 21 effective drinks - the dosage equivalent of 252 ounces of beer.
At the outset of Federal Prohibition, most alcohol consumption in the United States was still in the form of beer and wine, relatively impotent dosage forms. The decreases in alcohol consumption in the early years of Prohibition were accomplished by decreases chiefly in the consumption of beer. Those who drank, drank distilled spirits. Some illicit beverages came from smuggling, some came from illicit distilling, but much came from the diversion of alcohol made for use in industry (e.g., anti-freeze) or the preparation of food and medicines. Diversion can be thought of as a kind of smuggling and industrial alcohol was high-proof. The Jake was made by the addition of ginger root to diverted concentrated industrial alcohol. The U.S.P. standard required 75 percent alcohol, and most, but not all, Jake met this requirement. This meant that a 2 ounce bottle of Jake, easily concealed, delivered 1.5 ounces of absolute alcohol. A legal mixed drink of today delivers approximately one-third the alcohol. The Jake, illegal and potent, reflected the iron rule.
Fentanyl and its chemical relatives represent something slightly different but still reflect prohibition's usual relationships to potency. AMF and TMF are controlled substance analogues ("designer drugs"). The illicit chemist synthesized a product which resembled a controlled substance (fentanyl) but was (for a time) technically legal. As noted, fentanyl-like drugs are extremely potent, at least 100 times as potent as morphine. Potency means a number of things. Smoked opium delivers low doses of morphine but extracted and purified morphine is more potent. Opioids made from morphine modification (heroin, hydromorphone) are more potent. Synthetic opioids like fentanyl are more potent yet. So, 10 mgm of refined morphine will provide one dose, 10 mgm of heroin three doses, and 10 mgm of fentanyl one hundred doses. Yet the "high" of fentanyl is not better, more dramatic, or more intense than that of heroin. However, a very small amount of fentanyl is much more dangerous because a small weight may be sufficient to suppress respiration and cause death. Increased potency is not invariably dangsed on the hope that it will improve conditions in their neighborhoods. They hope that if the police come and get the worst drug offenders out, they won't have to confront the drug scene, day in and day out. This is the point at which our problem and your problem overlap. Open drug scenes have been growing in many European cities, interfering with what other people consider to be their legitimate right to public space. What is dramatically different about the two situations is that through purposeful non-enforcement of the law against low-level sellers who conduct their business out of public view, Europeans have managed to keep the street scene at a much smaller level. Because you allow some other ways of drug distribution to occur, without much police intervention, you manage to keep the street scene somewhat under control. That does not mean it is entirely nonproblematic. In fact, a number of markets have emerged in areas that many people travel through on a regular basis, and there is increasing pressure on the police to take action against them.
Until now, drug-policy reformers and harm-reductionists have been able to keep their focus on issues of reducing harm to drug users. Today, there is more pressure on them to take seriously the issues of public order - and to balance the needs of drug users against the needs of other people in the community. Unfortunately, in the United States, the effort is thwarted by law enforcement policies that are aimed specifically toward reducing drug use rather than maintaining public order. Because of this, drug policy in the United States not only maximizes harm to individual users, it maximizes harm to the broader community. Those of us who are critics of this policy are very glad to be at this conference. We are counting on your moving forward with a humane and effective drug policy that we will be able to follow. Drug sellers, of course, are motivated to market their products fairly aggressively because they want to make themerous, but is likely to be so among new users or those with diminished tolerance due to recent abstinence or access to particularly low-potency drug. The increased potency of fentanyl was dangerous because injectors lacked information about the content of the product. The widespread growth of use of distilled liquor during prohibition illustrates another potency problem of alcohol: chronic toxicity. The prevalence of cirrhosis in the U.S. had declined steadily from 1905-1906. Most believed that this had to do with declining consumption. By 1921-1922, the decline in cirrhosis reversed and its prevalence increased steadily during the rest of Prohibition.l2 This toxicity probably had to do with increased potency and the tissue toxicity of potent distilled alcohol.
The example of contamination illuminated by The Jake story is clear. Illicit product is not subject to quality-control inspection and it's makers are not subject to manufacturing process review. Although some Jake entrepreneurs were quasi-legitimate and sold other medicines, most hearing the bad news simply closed their doors and walked away. Few stayed around long enough for sufferers to sue. Much Jake was abandoned, at rail stations and trucking depots.
Most illicitly manufactured or illicitly refined drug is contaminated or adulterated. The illicit chemist seldom has the combination of skill, resources or commitment to produce a clean product. Most illicitly synthesized metamphetamine, phencyclidine or methacathinone is sold with reactants or precursor chemicals still in the mix. Material extracted from plants is often contaminated with residues of the processing. Illicit cocaine, for example, typically contains residues of gasoline, kerosene or manganese, all used in extraction. Fortunately most contaminant chemicals in low doses are not highly toxic. Occasionally however this luck fails. Another Rphenylpiperdine, meperidine, is widely sold in the U. S. as Demerol . An illicit chemist attempted the synthesis of a meperidine-like compound, MPPP. This synthesis easily goes awry and yields small amounts of MPTP which causes irreversible brain damage resulting in a Parkinsonion Syndrome. 13
Contamination and increased potency represent different processes and yield different problems in drug substances. However, they both are more related to prohibition than other forces.
Others writing in this volume have discussed the generation of criminal enterprise by formal prohibition and stringent controls. Desirable products not subject to legal trade become subject to illicit trade. An illicit retail trade is supplied by illicit manufacture distribution and franchising. The profits of illicit cocaine, marijuana, and heroin enrich illicit marketers and generate and maintain extremely large enterprises. Just as alcohol prohibition produced Al Capone, cocaine prohibition produced Pablo Escabar.
The Jake victims were derided and laughed at. It was widely held that they deserved what happened to them as did the thousands of blinded methanol drinkers. It is not enough to state that the laws of prohibition produce excluded marginal humans. In the United States it is clear that the marginalization of a group of despised people is the goal of the policy. To deny injectors clean needles and syringes ensures their harm. To spray marijuana fields with paraquat is a policy not solely for destroying plants, but harming users. American laws of prohibition often were generated by a fear and hatred of these perceived as dangerous: the Chinese immigrants smoking opium, the Southern European immigrants consuming alcohol and the non-white inner-city residents using heroin and crack.l4 An oppressive government denies to individual citizens the right to control their bodies and then despises them for harm done not by the substance but it's contaminated poor-quality version generated by those laws. It is of no surprise that those poisoned by Jake and fentanyl were given little sympathy and little consideration.
The Jamaica ginger story has broad dimensions. The marketing of a supposed medicinal extract supplied an affordable potent alcoholic beverage to farming and working class people in the Southern United States. In the waning days of Prohibition, a Northeastern entrepreneur decided to increase his profits by changing the formula of adulteration. He paralyzed thousands of drinkers and could not be prosecuted under Prohibition law, but was lightly punished by The Pure Food and Drug Act whose labeling and manufacturing rules he evaded. Among the charges was one that his Jake often was low in ethanol content. Black and white unschooled musicians who had entered the commercial recording industry almost accidentally produced an amazing number of songs about the episode, often accurately describing the impotence secondary to spinal cord damage which went unmentioned in the medical and newspaper reports. 15 Despite all of these facets, it is most important that the Jake episode be viewed now and described accurately as a tragic event directly caused by a policy of prohibition. Despite having faded from memory and often mistakenly described today as related to methanol, its sad lessons are everywhere repeated (and ignored) as the contaminated, potent, and deceptive products generated by prohibition continue to harm users. There is no essential difference between the poisonings with TOCP and TMF. In the absence of proof that prohibition sigluficantly reduces consumption, the harm it generates serves as a clear justification to consider policies of legalization.
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