Peter R. Martin: Historical Vocabulary of Addiction, Vol. II
Epidemic
The noun and adjective epidemic are borrowings from either the French épidémique or the Latin epidemicus according to the electronic version of the Oxford English Dictionary (OED). The French épidémique was derived from Middle French or from its earlier form épidimique. The French épidémique is, in turn, a derivation from post-classical Latin epidemicus, epidimicus. The noun epidemicus is a joining of epidemia derived from the noun epidemy and the suffix ‑icus ‑ic (typically used in “adjectives, immediately representing French -ique”) from classical Latin.
The original meaning of the noun epidemy was: “an acute disease that arises suddenly and unexpectedly and affects many individuals.” More recently epidemy was defined as: “a sudden [widespread] occurrence of such a disease.” A very early example of the use of epidemy in the English language can be found in the translation of The Golden Legend by William Caxton (c. 1422–c. 1491), a merchant, diplomat and writer who is thought to be the first person to introduce a printing press into England in 1476 (Voragine and Caxton 1483): “A grete pestelence, whiche was called the botche of impedymye.” The compiler of this original collection of the legendary lives of the most important saints of the medieval church was Jacobus de Voragine (c. 1230–1298), an Italian chronicler and archbishop of Genoa.
The noun epidemy was on occasion specifically used in place of or combined with the noun plague (now rather specifically defined in OED as: “An infectious disease characterized by high fever, initial involvement usually of lymph nodes or the lungs, haemorrhage, and shock, caused by the bacterium Yersinia pestis, chiefly transmitted to humans from rodents… by fleas, and occurring as isolated cases, small outbreaks, and major pandemics; an outbreak or occurrence of this.”). Of note, even plague which is now considered infectious was not initially so (e.g., the now obsolete meaning: “A sporadic disease or disorder, especially of a specified kind.”).
+Analogously, the figurative meaning of epidemy focuses on prevalence of an occurrence, rather than the etiology, namely, “A sudden, widespread occurrence of a phenomenon, typically an undesirable phenomenon.” Thus, despite their eventual association with communicable agents, words related to epidemy can be used in reference to phenomena that are not infectious in nature, such as drug/alcohol use and addictive disorders (see below).
Earliest evidence in OED for the use of epidemic in the English language is by the English writer and physician Thomas Lodge (c. 1557–1625) in A treatise of the plague containing the nature, signes, and accidents of the same… (Lodge 1603): “An Epidemick plague, is a common and popular sicknesse, hapning in some region, or countrey, at a certaine time,..producing in all sorts of people, one and the same kind of sicknesse.” The OED definition of the adjective as used by Lodge is: “Of an acute disease, especially, one that is not usually present in a region or population: affecting many individuals within a short period of time; suddenly and widely prevalent.” Lodge and his contemporaries had very little knowledge of the etiopathogenesis of an epidemic or the plague beyond recognition of the similarity of clinical signs and symptoms in many of the affected individuals.
These words have remained in common usage until the present, but with changes in meaning based on an evolution of the scientific understanding of infectious agents and processes (Snowden 2020). Physicians have long been intrigued by how the occurrence of certain acute conditions exploded within a population over a short period of time with sometimes deadly consequences. But even before the major advances in microbiology of the second half of the 19th century many imaginative and creative ideas were proposed to explain the phenomena that characterized epidemics. The ideas of the English surgeon Sir William Blizard (1743–1835), founder and first president of the Hunterian Society, presented in his article Observations on some epidemical Effects represent one example (Blizard 1792):
“The laws of the animal economy, and particularly those that direct the constant efflux from exhalent arteries, and the continual influx into the absorbents, so expressive of the connexion of the body with surrounding matter, must be understood. The weight and temperature of the air, its moisture, and what else it may contain, must be continually subject of investigation. The winds too, as affecting the properties of the air, and directing the course of matter floating in it, must not be less regarded: but as all the parts of nature are linked together, are dependent upon, and in their changes affect each other, the powers of the mineral and vegetable kingdoms upon the air and body must also he considered; nor should the influence of the planetary system be unheeded: for, doubtless, effects as certain, though less manifest than the seasons and their varieties, arise from the courses of orbs, whose distances, or lengths of periods of revolution, make them but little the objects of philosophical attention.
Blizard proceeded to explain why it is important that we understand the source(s) of epidemics and what we may learn from these investigations primarily from the perspective of a surgeon:
“The nature of symptoms that may supervene in wounds, and other accidents, will be better understood.
“The reasons why certain operations at one time prove generally successful, and at another time otherwise, will appear.
“The periods when particular parts of the body may more or less safely bear operations will be pointed out.
“The observation so frequently made at hospitals, that many cases of the same nature “happen together,” will be explained.”
Finally, Blizard closed with the importance of understanding epidemics for all of medicine:
“The subject of epidemics appears to be worthy the attention of particular societies in different countries. Other branches of philosophical research have been greatly improved by bodies of men particularly engaged in their cultivation: and the fame success may reasonably be expected from like exertions in respect of epidemical causes and effects.”
The above analysis by Blizard is consistent with a humoral etiology of epidemics. Humoralism derives from the legacy of Hippocrates (1950) and Galen (1997). Hippocrates of Kos (c. 460 – c. 370 BCE) was a Greek physician of the classical period who is even today a highly influential figure in the history and the traditions of medical practice. Aelius Galenus or Claudius Galenus (129–216), often anglicized as Galen of Pergamon, was a Roman and Greek physician, surgeon, and philosopher, recognized as the most accomplished medical researcher of his era.
The specificity of epidemics and the notion of individual susceptibility was recognized before any actual sources or responsible agents were discovered. The American physician, Joseph Mather Smith (1789–1866), well known for his work on febrile illnesses, published Elements of the Etiology and Philosophy of Epidemics (Smith 1824). That a treatise published in the New World was reviewed in the celebrated British Medico-Chirurgical Review and thus influenced scholars in the Old World was not a common occurrence at the time. A quote from this review refers to individual vulnerability to epidemics, called “poisons” by Smith:
“Strictly speaking a unity of disease can exist only where there is a unity of cause. If the same poison operate on individuals whose susceptibilities are different, grades of one disease will be the consequence. As a general truth, therefore, it may be said, that different poisons produce different disorders, each of which has different grades that collectively form an unit.”
An advance in understanding of the causation of epidemics occurred with discovery and promulgation of the germ theory (Snowden 2020). These advances were primarily the result of contributions to the scientific basis of modern medicine by three researchers. Louis Pasteur (1822–1895), a French chemist, pharmacist and microbiologist proposed that an epidemic such as cholera was caused by a specific bacterium, rather than by spontaneous generation. He proved that such microbial life when cultured could be inoculated into experimental animals to cause the disease, but not when it was boiled in a sterile flask prior to inoculation as this caused its destruction. Heinrich Hermann Robert Koch (1843 –1910), a German physician and microbiologist proposed how to rigorously establish causality between specific microbiological agents and unique infectious diseases (Koch’s postulates). Finally, the British surgeon, medical scientist and experimental pathologist Joseph Lister (1827–1912) was one of the first to put into medical practice the ideas of Pasteur using antiseptic techniques to reduce the then all-too-frequent infectious complications of surgery. These influential scientists provided the foundation for understanding infectious epidemics documented since the start of human history.
We must consider another notion of epidemic in a discussion of addiction. Of the several definitions listed in OED, one for its use as an adjective and another for the noun seem appropriate in this analysis. The adjective is defined: “More generally: designating a health-related condition or behaviour that occurs more often than is expected or that is widely or increasingly prevalent in a group or population.” The relevant definition for the noun is: “An increase in the prevalence of a non-infectious health-related condition or behaviour in a group or population.”
These definitions if applied to behavioral conditions do not require infectious pathogenesis or transmission. The precise cause of such noninfectious epidemics of behavioral conditions remains to be fully elucidated. Even for behavioral conditions like addictive disorders, relevant agents (alcohol/drugs) represent only one factor that must occur within a susceptible individual in a predisposing environment, namely such epidemics are causally multivariate.
A very early reference to behavioral disorders as epidemic is found in a quotation from Thomas Arnold (1742-1816), an English “Doctor and Mad house owner of Leicester Lunatic Asylum,” known for describing 13 different types of insanity (divided into two major groups: Hallucinations and Delusions) in his treatise Observations on the Nature, Kinds, Causes, and Prevention of Insanity, Lunacy or Madness (Arnold 1782): “As all these absurdities abounded in the dark ages of ignorance and credulity, so the several sorts of epidemic Insanity…have been the peculiar production of those ages.”
The emphasis in the present discussion is the relatively well-described group of addictive disorders that can affect an unexpectedly large proportion of the population during finite periods. This concept of a behavioral epidemic was referred to in a quotation from an 18th century manuscript An Epistle to the Fair-sex on the Subject of Drinking in which the word is used as an adjective (Anonymous 1744): “Whether this Malady [sc. female drinking], that is epidemic, has, in all Places, the like Bad effects.” Another relevant quotation in which the noun is employed is from a magazine American Museum (Anonymous 1791): “Could any degree of sobriety be looked for in an air, tainted…with the principles of intoxication, engendering drunkenness as an epidemic. Would not any one think, that where such is the rage for whiskey, that it was all in all, the one thing needful, the alpha and omega of life.”
Therefore, even though infectious processes are typically considered the etiology of epidemics, there are many examples of behavioral conditions for which the use of the word is quite appropriate. This hybrid usage of the word may be explained by the fact that our understanding of the pathogenesis of both behavioral and infectious conditions were enigmatic for centuries and the scientific knowledge that allowed valid dichotomization of the sources of epidemics is a relatively recent development in human history.
Addiction involves behaviors of which the out-of-control and self-destructive use of alcohol and drugs is central. The availability of these substances may be conceptualized as causal in epidemic use, analogous to microbes. Alcohol has been one of the most widely used substances worldwide throughout history. Out-of-control drinking of alcohol has been associated with a range of social and health problems, including violence, accidents and disrupted family life and chronic diseases such as psychiatric comorbidities, liver disease and cancer. Americans today use alcohol in a harmful manner more often than any other drug except tobacco.
In the United States, there was a significant increase in alcohol consumption and related problems during the late 19th and early 20th centuries which may be considered to have reached epidemic proportions, leading to the implementation of Prohibition laws in the 1920s. Under Soviet leader Leonid Brezhnev (1970s-1980s), the government encouraged heavy alcohol consumption as a way to increase revenue and control the population. This resulted in a significant increase in alcohol-related health problems, including psychiatric complications, liver disease, alcohol poisoning and premature death.
There have also been repeated epidemics of alcohol use documented earlier in history. Due to high taxes on imported spirits in England, gin became the cheapest and most accessible alcoholic beverage in the early 18th century. This led to a surge in alcohol consumption, particularly among the poor, and resulted in widespread drunkenness, crime and social problems, the so-called Gin Epidemic of 1720 to 1751 for which government interventions were eventually necessary to reduce the sale of alcohol (Warner, Her, Gmel et al. 2001). These government actions are quite analogous to those currently implemented by the U.S. government in response to the opioid epidemic (see below).
Tobacco use is a major cause of preventable death and disease worldwide and has been associated with addiction and mental health conditions, cancer, heart disease and many other health problems. In the United States, there was an increase in tobacco use to epidemic proportions during the mid-20th century, fueled in part by highly effective marketing strategies employed by tobacco companies. Advertisements actually suggested health benefits from smoking and were often directed to youth, the most vulnerable to eventually developing lifelong smoking and its complications. Although the socioeconomic factors that have contributed to epidemic tobacco use vary throughout the world, recognition of the multitudinous health consequences has led to development of some exceedingly successful prevention strategies, especially in the developed world (Yang, Song, Yoon et al. 2015). Unfortunately, the problem of smoking remains unabated in many countries (Currie and Ray 1984). Overall, a combination of public education, policy changes, and regulatory action have contributed to the reduction in tobacco use over the past 50 years.
In the mid-19th century, there was a widespread epidemic of opium addiction in China, fueled by the large-scale production and trade of opium by British and American merchants to that country (Bradley 2015). The epidemic led to widespread poverty, crime, disease and the destruction of Chinese society and its growing economy (Martin 2019b). The current use of epidemic also seems quite appropriate to describe the widespread devastation from use of opioids and associated overdose deaths in the United States (Compton and Jones 2019; Fraser and Plescia 2019; Zai 2024).
The U.S. Centers for Disease Control and Prevention (CDC) has popularized the notion that opioid overdose deaths in the population are the result of three distinct waves of an opioid use epidemic (Spencer, Garnett and Miniño 2024). The first wave is attributed to increased prescribing by physicians of opioids in the 1990s (Keefe 2021), with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone). The second wave is thought to have begun in 2010, with rapid increases in overdose deaths involving heroin perhaps as a consequence of government attempts to reduce opioid prescribing by physicians (Martin 2020). The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illegally made fentanyl shipped to the U.S. from China via Mexico (Martin 2019b). The market for illegally made fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills and stimulants. Most recently, the epidemic of opioid overdose deaths has been considered to have evolved into a fourth wave involving co-administration of stimulants such as cocaine and methamphetamine (Friedman and Shover 2023).
A sophisticated analysis of the epidemic of substance use disorders in the United States focusing on overdose deaths resulting from availability and use of different drugs and socioeconomic forces has been implemented (Jalal, Buchanich, Roberts et al. 2018):
“The U.S. drug overdose epidemic has been inexorably tracking along an exponential growth curve since at least 1979. Although there have been transient periods of minor acceleration or deceleration, the overall drug overdose mortality rate has regularly returned to the exponential growth curve. This historical pattern of predictable growth for at least 38 years suggests that the current opioid epidemic may be a more recent manifestation of an ongoing longer-term process. This process may continue along this path for several more years into the future. Paradoxically, there has been substantial variability with which specific drugs have become dominant in varying populations and geographic locales. This variability all but negates the possibility of confident predictions about the future role of specific drugs. Indeed, it is possible that a future overdose epidemic may be driven by a new or obscure drug that is not among the leading causes of drug overdose death today. Understanding the forces that are holding multiple subepidemics together onto a smooth exponential trajectory may be important in revealing, and effectively dealing with, the root causes of the epidemic.”
Therefore, while opioid use has captured the imagination of the American public due to risk of overdose deaths, the opioid epidemic (recently accompanied by stimulants) is actually interwoven in the last few generations with addiction-related epidemics involving other substances than opium or stimulants. Surveys conducted by various government agencies have monitored changes in the prevalence of various forms of drug use and health consequences since the 1960s (Martin 2019a). These epidemiological surveys have documented epidemics of problematic use of marijuana in the 1960s, heroin in the 1970s and cocaine in the 1980s. Although no single illicit drug was used in epidemic proportions in the 1990’s, it is in this period that the current opioid epidemic began. It is also essential to understand the role of licit drugs, especially alcohol, and prescribed central nervous system depressants that are also identified in body fluids of those who die from so-called opioid overdoses (Tori, Larochelle and Naimi 2020).
Finally, when considering the historical development of the meanings of the word epidemic, it is noteworthy that infectious and addiction-related epidemics are often mechanistically interrelated (Friedman, Pross and Klein 2006). As the intravenous use of opioids and stimulants increased at various times over the last 75 years, the cost to society of epidemic drug use was compounded by transmission of contagious viral particles through sharing of hypodermic needles, contributing to recent infectious epidemics of hepatitis C and acquired immunodeficiency syndrome.
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June 13, 2024