This paper presents a picture of how the patterns of opium use have changed in Turkmenistan over more than 100 years and the relationship between these transformations and formal and informal social controls of drug use. From the late 18th century, when opium use began to become a social problem, informal control weakened. Eventually, in the late 19th century, formal control was introduced, aimed at the prohibition of drug trade and use. From that time, the intended and unintended outcomes of implemented policies led to changes in the demographic patterns of users and the social-medical consequences of opiate use. The anti-drug policies, where criminal prohibition coexisted with strategies aimed at raising the population's general living standards and at providing free access to health care, were effective up to the early 1980s. New political and social–economic realities in the 1980–90s have radically changed the drug scene in the country, with heroin trade and use as the main concerns. The government's reaction, while following the old paths, has included new elements, based mainly on ideas of national consolidation.