Most people would not use “opioids” and “American history” in the same sentence. Yet opioid use has been a part of the American fabric since colonial times, its popularity rising and waning in cycles. How this nation responded to each lingering cycle of opioid use changed over the years, alternating from offering champagne cures to imprisoning physicians and banning drugs. While some efforts may have worked to subdue a given cycle, others did more harm than good. There’s a great deal we can learn from past successes and failures when responding to the nation’s current public health emergency.
America’s First Drug Epidemic
America’s first opioid epidemic was eerily similar to today’s crisis in that it began with not recreational but medicinal use. This first epidemic centered on morphine, which was first isolated from opium in 1803. In 1853, with the invention of the hypodermic syringe, morphine could be injected for fast pain relief. Injecting also produced an instant euphoria, or rush, that was not possible with other routes of administration. The syringe, a godsend to patients who required surgery or suffered serious injury, would also prove to be the method of delivery most likely to lead to addiction.
In the mid-1800s, the term medicinal was used quite loosely. Drug peddlers, who needed neither a degree nor expertise, marketed patent medicines that contained untold amounts of poppy-derived substances for ailments ranging from migraines to dysentery. Any quack on the street could sell them to passersby. By the time of the Civil War (1861–1865), opium and morphine lined many medicine cabinets in the form of laudanum (a common tincture of alcohol, water, and opium) or morphine powders and pills. On the battlefield, injectable morphine and morphine pills were invaluable in easing the suffering of at least some wounded soldiers. The effect of morphine’s widespread distribution was apparent after the war, when thousands of soldiers found themselves addicted to the drug.
However, in the nineteenth century, women, not veterans, made up the largest number of opium and morphine addicts. Doctors regularly prescribed laudanum for menstrual cramps and migraines. At the time, addiction was recognized not as a disorder but as a moral weakness or bad habit, like gambling or swearing. No one really knew how to deal with it, yet people afflicted with opioid addiction were generally tolerated.
America’s first opioid epidemic, which lasted from about 1865 to 1895, affected mostly whites, as blacks had very limited access to medical care. The drug of choice was morphine. But that soon gave way to an even stronger opioid.
Enter Heroin
Heroin, which is four times more potent than morphine when injected, first showed up in America in 1898, bottled as a cough suppressant blatantly and innocently labeled “Heroin.” Some experts touted it as nonaddictive (though researchers did come to the opinion that heroin was highly addictive and could lead to “deplorable results”) and not nearly as effective a painkiller as morphine. Initially, the producers of heroin (Bayer, as in Bayer Aspirin) distributed it as a low-potency elixir, pill, pastille, or tablet to treat respiratory disorders, such as whooping cough, bronchitis, and consumption. Physicians rarely gave potent injections, and so it was not a great source of medical addiction.
But if heroin as a healing agent did not create addicts, heroin as a recreational agent did. By the start of World War I, heroin was an established street drug cheaper than opium. The Prohibition Act of 1920, which forbade the production and sale of alcohol, opened the door to even more heroin use by people looking for a substitute high.
Attempts to Stop Opioid Use and Addiction
Most drug epidemics do not completely end but subside and then linger, leaving a trail of new drugs for a new generation of people, usually teenagers and young adults looking to experiment. America’s first opioid epidemic didn’t really end but faded away. First, by the turn of the twentieth century, addicted Civil War veterans had either passed or were nearing the end of life—and so a generation of opioid users was dying off. Second, in 1906, the US government under President Theodore Roosevelt passed the Pure Food and Drug Act, which required that all products display a list of their ingredients as well as meet certain purity standards. At the time, the idea of giving the federal government so much power was radical. But it was the Progressive Era, and an active and vocal Pure Foods Movement begun in the 1870s had ensured that most people understood that the use of opium, morphine, and heroin could have devastating consequences. After 1906, patent medicines that listed addictive substances as ingredients were left on the shelves to collect dust. But listing an ingredient is not the same as banning it, and so those who wanted morphine still had access.
Government intervention helped limit the number of new cases of addiction, but at the time, addiction was understood far less than it is today. For the most part, attempts to help addicted individuals failed miserably. Patent medicines claiming to cure addiction contained some of the hair of the dog, as it were, including morphine and alcohol. Some were even poisonous, with such ingredients as strychnine. Withdrawal, rest in a sanatorium, fresh air, and exercise, along with champagne and port wine, were also encouraged. Those who could not afford treatment tried to go “cold turkey” at home or were sent to psychiatric asylums. Relapse was the norm, as none of the treatments worked in the long term, but many a proprietor got rich off claiming to have the cure.
Some physicians, however, latched onto yet another form of treatment that wasn’t necessarily the most effective (and not always provided for the right reasons) but that they thought had potential: the narcotic clinic. In these specialized clinics, opium was prescribed to alleviate withdrawal symptoms, and morphine was given chronically to help people addicted to morphine. Doctors ran the clinics almost like the methadone programs of today. People addicted to opioids lined up two to three times a day to get a short fix. Giving addicted people their drug of choice, in the same way they took it before, might not have done much to quell the desire to keep using, but it had a stabilizing effect. These folks had access to a doctor and medical care, so the harms of using were reduced. They weren’t given enough to overdose. And they were surviving. It didn’t work for everyone, but at least it was a stab at a medical rather than a criminal solution.
Criminalization and antidrug campaigns were also used to curb usage, but these efforts sometimes backfired. When, in 1909, the US government tried to stop opium use by outlawing the substance, opium smoking became fashionable among the wealthy, who could afford the now higher prices. The poor and middle class turned to cheaper drugs: namely, the much harsher heroin. Amid growing concern, the government passed the Harrison Act of 1914, which in essence created a model for how not to treat addiction. About 5,000 doctors were imprisoned for prescribing an opioid in an effort to help a patient, regardless of whether that treatment was beneficial. Terrified, doctors either closed their narcotic clinics or secretly sold the contraband. This fostered the birth of the pill mill—a place where anyone with cash can buy a doctor-prescribed narcotic, whether medically advised or not.
The police, rather than the traditional medical board, started overseeing doctors, which created a great deal of fear within the medical profession. What stems from fear usually creates more problems, and this phenomenon had the unintended effect of hurtling the treatment of opioid addiction straight into the Dark Ages. The nation moved away from treating addiction as a medical problem to seeing it as a criminal act. Doctors and their addicted patients were prosecuted, and the whole profession of taking care of the addicted was decimated: Treating addiction with opioid medications was illegal, and if you prescribed opioids or a painkiller to patients who could not stop using, you were prosecuted if you were caught.
The last narcotic clinic closed its doors in 1921. Over the following decades, researchers explored everything from carbon dioxide therapy to LSD as ways to treat opioid addiction. It would take fifty years and another bloody war before a viable medical treatment for people addicted to opioids surfaced—or rather, resurfaced.
Opioids as Treatment
The Psychedelic Sixties and Seventies: A Return to the Medical Model
The US government banned heroin in 1924, except for use in severe medical cases. But as a street drug, heroin never went away. The end of World War II and the Korean War brought about a dramatic rise in heroin use. By the 1960s, heroin use increased, in part because a large number of baby boomers were at that age when youths typically experiment with drug use. Inner-city crime, much of it drug related, was at an all-time high, and a generation of youths was dropping out and nodding off. The other, more sensitive, issue was that Vietnam War veterans were coming home with a proclivity and vulnerability for using heroin, which was readily available and widely used in the war zone by servicemen to cope with the pain and trauma of combat. Much of the nation struggled to see young soldiers coming home and injecting heroin. They had fought for the country, and their use was not a moral failing, but stress and trauma related. The government did not see these veterans as hoodlums but as heroes.
In 1969, an estimated 315,000 Americans were addicted to heroin. A short two years later, the number of addicted reached 560,000. Although these numbers pale in comparison to today’s epidemic, they were staggering at the time and had nearly managed to outpace the nation’s first (and much longer) opioid epidemic. Something had to be done. Smack dab in the middle of the largest crime and drug crisis since the beginning of the century, President Richard Nixon and his advisers advocated methadone treatment.
Methadone, a synthetic opioid, first came about during World War II, when the rigors of war rendered opium in short supply but the need to treat pain was only expanding. German scientists looking for a morphine substitute fabricated it from scratch. Methadone is a narcotic similar to other opioids, but it produces only minimal intoxication when taken orally and regularly. It also performs an impressive backflip: When taken daily, it reduces craving and alleviates withdrawal symptoms in OUD patients. The patient feels completely normal. If the patient is then exposed to another opioid such as heroin, they are not able to feel the high.
The Germans never used methadone as a painkiller. Their tests showed too many side effects. But postwar, a refined version of the drug made its way into the United States as a prescription painkiller. By the 1970s, because of its unique qualities, including limited euphoria and long duration of action, methadone had become a first line of treatment for heroin addiction during the nation’s second opioid epidemic, which favored heroin.
The Nixon administration poured millions of dollars into addiction treatment programs. The government expanded treatment with methadone and funded research to develop alternative medical strategies, including naltrexone and later buprenorphine. This event marked the beginning of the modern, medically focused approach to treatment of opioid addiction. Prior to that, “medical” treatments of heroin addiction had been not only mostly unproven but also ineffective, dangerous, and potentially lethal.
The Birth of Methadone Maintenance Therapy
It all started with a program in New York City, which in the 1960s was the heroin capital of the United States. The idea of using methadone as a medicine to treat opioid addiction was first conceived by Dr. Vincent Dole, an endocrinologist who saw opioid addiction as a metabolic disorder of the brain that required sustained medical management to correct, though not cure, abnormalities. In other words, Dole saw addiction as a scientific problem with a scientific solution. He, along with Drs. Marie Nyswander and Mary Jeanne Kreek, both physicians working at Rockefeller University, developed and implemented methadone maintenance therapy (MMT), which involved dispensing liquid methadone to heroin-addicted individuals from specialized clinics.
Patients maintained on methadone would line up each morning in front of the clinic window, where a nurse would dispense the daily dose of methadone adjusted for each patient. For many patients, the dosage was not sedating but enough to keep cravings and withdrawal at bay. Large numbers of MMT patients went to work and led reasonably normal lives—and many of these first patients continue to do so today. MMT did not work for all, however. Some continued to use heroin or other drugs despite high doses of methadone and weekly counseling. But overall, the methadone-based treatment had the lowest failure rate of any program for treating opioid addiction: 30 to 40 percent of patients had minimal to no benefits from methadone treatment compared to 70 to 90 percent failure in other programs.
Methadone clinics, which are now known as opioid treatment programs (OTPs), had a strong initial foothold in the recovery movement. Counseling was an essential component of treatment, and many counselors were patients themselves and served as role models. Treatment was as much about the improved health, wellness, and quality of life as it was about reducing crime, demand for the drug, and overdose incidents, which were alarmingly high. In the mid-1970s, more than 650 people died every year from a heroin-related death in New York City alone. By comparison, the New York City Health Department reported a similar rate of 630 deaths in 2011, though by 2016 this figure had more than doubled.
As the reach of the methadone programs grew, the focus of treatment began to shift, from the remission of addiction and personal recovery to a reduction of harms to society (crime, costs, and safety). Disconnected from the idea of an abstinence-based recovery, MMT was a means to manage the swelling tide of heroin users from all walks of life, all across the country.
By 1984, three thousand programs were treating opioid dependence in the United States. Some programs began offering naltrexone, an opioid blocker given to patients after detoxification to prevent relapse, as an alternative to methadone. Other programs offered psychiatric, faith-based, or Twelve Step approaches, as well as long-term residential treatment in therapeutic communities such as Daytop. None of these approaches was overly successful in treating OUD except in a small group of patients.
Methadone Under Fire
Methadone clinics are still helping to save lives and reduce harm. But they are not without controversy. Methadone is a powerful medicine with side effects and a potential for harm if not used properly. Treatment with methadone also keeps patients physically dependent on opioids, meaning that they have to take the medicine every day or will suffer an unpleasant opioid withdrawal. If taken in a higher dose than prescribed, methadone can produce intoxication or even death, especially if taken in combination with other sedatives or alcohol. Because of these similarities to heroin, and a disconnection of methadone treatment from the focus on personal recovery, critics view methadone programs as “exchanging” one addiction for another—addiction to heroin for addiction to methadone.
This reaction, in fact, was nearly universal, with the notable exception of Bill Wilson, cofounder of Alcoholics Anonymous (AA), the first Twelve Step program. In a 1991 editorial entitled “Addiction as a Public Health Problem,” Dr. Vincent Dole wrote the following: “[Bill Wilson] spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. . . . He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps.”
Still, MMT was under fire. Negative portrayals of inner-city programs in the press further stigmatized methadone clinics. To this day, most communities are loath to permit one to operate in the area, for fear they will attract heroin dealers looking for customers like bees to honey. Strict regulations have made the clinics bureaucratic nightmares. In response to problems seen in some methadone programs that became profitable “methadone mills,” the government clamped down on methadone clinics. Nowadays, multiple governmental agencies issue regulations and provide oversight. Setting up a new methadone clinic can take more than a year, and treatment is often guided by regulations more than patient needs. Being maintained on methadone still produces stigma, not only from neighbors, but from others in recovery from addiction, from families, and even from some medical professionals.
Despite these setbacks, methadone is considered the gold standard of opioid addiction treatment worldwide. Even such countries as China and Iran, initially reluctant to embrace this model of treatment, are now rapidly scaling up efforts to establish methadone clinics. Leaders are seeing the benefits to individuals and society. As part of an effort coordinated by the United Nations Office on Drugs and Crime, I am helping to train medical providers to implement methadone treatment programs in Afghanistan, one of many places where effective opioid treatment is very much needed, as approximately 5 percent of the population is using opioids. Some countries, however, most prominently Russia, remain adamantly opposed to using potentially addictive substances to treat addictions.
From Heroin to AIDS
MMT did not end the heroin epidemic—in 1986, an estimated 500,000 Americans were addicted to heroin, a number just shy of the 1971 figure—although it certainly improved a lot of lives. MMT also helped to demonstrate the utility of a medical approach. Like the earlier narcotic clinics, methadone maintenance has a strong component of harm reduction as the first step in preventing adverse health consequences. By eliminating the need for needles and transactional sex, for example, methadone maintenance protects former heroin users from the likelihood of contracting HIV/AIDS. However, it can go beyond harm reduction and allow some patients to “live self-directed lives, and strive to reach their full potential,” which is the Substance Abuse and Mental Health Services Administration’s definition of “recovery.” But make no mistake. Addiction was still highly stigmatized as a deviant and criminal behavior and still not seen as a medical condition requiring medical attention.
The heroin epidemic, like the nation’s earlier opioid epidemic, gradually faded away for three major reasons: First, many Vietnam vets gave up heroin once the trauma of the war began to subside and the triggers that encouraged drug use slowly disappeared. Veterans settled in at home with their families and at their new jobs. Second, by the mid-1980s, new drug users preferred cocaine, which ignited a new drug epidemic. And third, the AIDS epidemic was well under way, discouraging the use of disease-transmitting needles.
Lessons from the AIDS Epidemic
In 1981, AIDS was a new disease that the Centers for Disease Control and Prevention described as “a rare pneumonia contracted by young gay men.” Soon afterward, intravenous heroin users and sex workers were also identified as high risk for contracting HIV. Within sixteen months of the first reported case, 40 percent of people diagnosed with AIDS were dead. While scientists struggled to find the cause and treatment, the gay community quickly mobilized, creating a movement to fund-raise for research and pressure the government to speed up the development of drugs to counteract the HIV virus, which gradually destroys the immune system of infected individuals.
Massive efforts went into training clinicians to treat viral infections in immunity-compromised patients. In 1987, with the release of the first HIV/AIDS medication, Congress provided $30 million in emergency funding to states to pay for the medications. This evolved into the AIDS Drug Assistance Program, which now exists in every US state and territory. The powerful and proactive grassroots organizations used their money and connections to ensure HIV/AIDS patients received medications at no cost. Grants were used to pay for treatment and campaigns initiated against stigma and misinformation. The AIDS epidemic went very quickly from being thought of as a stigmatized disease or a punishment for moral depravity to a disease that needed to be stopped—akin to any transmittable disease, such as tuberculosis.
As HIV/AIDS spread globally, the world, it seemed, was rooting for a cure. When medications became available, the medical community implemented them immediately on a massive scale, and the rate of deaths decreased dramatically in the United States. Most people accepted HIV/AIDS as a chronic disease that required lifelong treatment on medication, and sensationalizing the lifestyles of affected individuals gradually stopped. Moralizing, waving fingers turned into compassionate, helping hands. Even the religious right saw the urgency. HIV/AIDS had been mainstreamed, and this perspective encouraged funding and treatment. In 2016, the 21st International AIDS Conference took place, reflecting the ongoing impact of the large-scale, coordinated efforts to ensure that those with the infection continue to receive help.
HIV/AIDS hasn’t gone away, but the number of lives lost to it has seen a dramatic decline. At its height in 1995, 50,000 people lost their lives to an AIDS-related illness; two years later, after the highly active antiretroviral treatment was introduced, annual deaths were down to approximately 20,000. Today, just over one million Americans are living with HIV, the number of new infections decreased by 18 percent between 2008 and 2014, and fewer than 7,000 people died in 2014 directly because of HIV.
In Europe, opioid addiction is viewed in the same way that AIDS is now seen in America: as a medical problem that requires medical attention, funding to provide free or subsidized treatment, research to improve medical treatments, and compassionate support. The United States is not quite there yet. Close to 2.5 million Americans have OUD, and about 400,000 have died from an opioid-related condition since 1999, despite the fact that there are three FDA-approved medications to treat OUD and prevent overdose deaths. Only a small percentage of individuals living with OUD receive proper treatment.
Although President Donald Trump declared the opioid epidemic a national emergency in August 2017, two months later he downgraded it to a public health emergency, which carries less weight in terms of funding. As of this writing, various commissions have outlined recommendations, and some additional money has started flowing into the system. At the same time, budget cuts have decreased funding for the Substance Abuse and Mental Health Services Administration, the nation’s leading addictions agency. Furthermore, tax cuts will subject millions of people to losing health insurance coverage, including for addiction treatment. Meanwhile, the rate of overdose deaths is accelerating. More than forty-two thousand people died from opioid use in 2016, a figure that is neck and neck with deaths from the AIDS epidemic at its peak. The US moved much faster in its response to the HIV/AIDS epidemic than it has through the current opioid overdose epidemic. OUD is a different disorder, but it requires the same kind of dynamic to effect change.
The Painful Steps Leading to the Current Epidemic
The current opioid epidemic started within the medical community with good intentions—to relieve pain in patients. But a confluence of seemingly unrelated factors created a powerful, unstoppable force. It started with prominent pain doctors, who had little training in addictions, advocating that painkillers could be used safely in most patients and would not cause addiction. They pushed for primary care providers, most of whom also have little to no training in addiction, to offer opioid pain treatment to people in chronic pain—a group long believed to be underserved by the medical community. This might have worked were the prescribing done under the supervision of addiction specialists, but that is not what happened. Prior to the 1980s, opioids were primarily used in end-of-life care for patients with terminal illness. In the late 1990s, the indications for use of prescription opioids were expanded to many medical conditions: everything from wisdom teeth removal to fibromyalgia. But the evidence for their effectiveness in those new indications was minimal, and the risks underestimated.
During this same period, the medical establishment operated by a few guiding principles that were, again, not based on any systematic evidence.
Medical tradition asserted that:
But none of these three generalizations is true. Anyone can fall prey to addiction. Chronic treatment with opioid painkillers eventually leads to tolerance and, in most people, the dosage must be increased or the pain addressed some other way. Lastly, physicians prescribing opioids for pain grossly underestimated how many patients presenting with pain have a co-occurring psychiatric problem, where additional caution is warranted. This was compounded by an unfounded belief that medical practitioners without psychiatric training would be able to recognize people who might be at risk of addiction and not offer opioids to them. In practice, it turned out to be much more difficult. People can excel at hiding what they do not want others to know, and addiction or addictive behaviors can be difficult to spot even by the trained professional. Overall, the addictive potential of opioids used for pain was grossly underestimated. Frequently, prescribing physicians neither informed patients about the risk of addiction nor implemented plans to monitor aberrant behavior and minimize the risk.
Seemingly innocent changes in health care, meant to bring more compassionate care, silently fueled the epidemic as well. In an effort to make the patient experience more respectful and meaningful, hospitals and clinics began employing the principles of patient-centered care, which include showing respect for patients’ preferences. This paved the way to patient self-report, which was ultimately seen as more valid than the objective finding of the physician. In the case of pain, the overarching belief became “pain is whatever the patient says it is.” Pain assessment then became an essential part of a medical evaluation, the same way that taking body temperature, heart rate, and blood pressure are. This practice gave complaints of pain a new prominence and focus, and, with a patient-centered approach to treatment, pain relief suddenly became a primary treatment goal. There was also a cultural shift. As a whole, people were moving away from accepting pain as an inevitability of aging. The discovery of pain necessitated the plan to relieve it: Pain-free living became the expectation.
Along with the recognition of pain, the mandate to treat it, reassurance about the safety of painkillers, and the ability of doctors to prescribe them widely (with little restriction) came efficient market forces advertising very powerful, newly formulated painkillers to doctors and patients alike, using strategies that were not only ethically questionable but also based on little scientific evidence. The fact that painkillers are highly desirable and many individuals are willing to pay a lot of money for them further drove up development, marketing, and sales of many “me-too” drugs, or drugs that duplicate the action of popular drugs already on the market. Once those market forces were unleashed, they were impossible to rein in, despite legal penalties.
Too Little, Too Late
Despite the fact that problems with prescription opioids develop in a large number of patients, known now for more than ten years, there was no change in guidelines or teaching about the use of these medications until 2016, when the CDC came out with a report that advocated for prescribing low doses for a short period of time. That is, if the opioids do not relieve pain, physicians are to stop prescribing them and look for something else. Accepting and enforcing these guidelines is another story. It is much easier to identify patients at risk, and treat them much more safely, than it is to manage those who have already developed a disorder, which then becomes chronic. As a result of these new pain treatment guidelines, fewer individuals will become addicted, but these guidelines will have little impact on people who are already addicted and might have already switched to heroin. For those who still have pain and have also developed OUD, we need to develop more promising therapeutic interventions.
What happens next is like clockwork: Once a patient is addicted to painkillers, and then finds access to painkillers restricted, it would be rare that the patient would not seek an alternative source to acquire the much-needed substance, as either heroin or pills one can get on the black market, which are often counterfeit. And most patients who use heroin will, over time, switch to more economical routes of administration, such as injecting. When high or seeking a fix, good judgment takes a backseat, and so next come risky behaviors, such as needle sharing and transactional, frequently unsafe sex. Down the road, the addicted individual seeks even cheaper and stronger opioids, such as fentanyl, and the risk of a deadly overdose escalates.
Most people who develop OUD will have a lifelong condition. Despite our having the necessary treatment to slow down the number of new cases, the overall number of people living with OUD will continue to grow, creating an increasingly large burden upon society, even though as many as 50 percent will perish after living thirty or so years with an active disorder. But if people decide to support and become vocal about a different approach to taking care of opioid-addicted individuals, we can drastically reduce all costs associated with OUD, including lives.
Asking Physicians to Turn the Tide
Physicians are expected to relieve pain. However, most are not trained, authorized, or even interested in treating addiction, because they do not consider it to be a public health issue in the same way that other chronic disorders are. Only about 4 percent of the 950,000 physicians in the United States are trained, certified, and prescribing buprenorphine, and 40 percent of US counties do not have a single buprenorphine provider. Even fewer physicians offer XR-naltrexone, another medication that can be used outside of specialty opioid treatment programs. Methadone programs number 1,400, but these are very unevenly distributed. Most are located in large cities, and half of all counties in the United States have no methadone program at all.
Much of the reluctance to treat OUD has to do with lack of training, as well as the prevailing stigma, myths, and misunderstandings about addiction. Some doctors in community health centers envision threatening or cunning heroin addicts, who haven’t bathed in weeks, nodding off or disrupting the office waiting room. These providers drop the idea of offering OUD treatment altogether. Yet treating OUD is no different than treating the many other chronic disorders that doctors manage every day. Many patients have uncomplicated OUD and respond to treatment promptly and fully.
Getting certified to prescribe buprenorphine requires eight hours of training for physicians and twenty-four hours for nurse practitioners and physician assistants, and many organizations that provide training also offer ongoing mentoring to help new providers as they begin to prescribe the medication. One of such efforts is Providers’ Clinical Support System (pcssnow.org), a federally funded project with a national reach. This program, which I am a part of, offers free training and support to all health-care professionals who would like to provide patients addicted to opioids with evidence-based care. In my experience of mentoring others through this program, prescribing buprenorphine to treat OUD is a relatively straightforward undertaking for most medical practitioners. After treating ten to twenty patients, most doctors get a general sense for medication effectiveness and how to minimize the risks. They begin to feel quite comfortable expanding it to many more patients. Physicians who begin working with this population find themselves pleasantly surprised at how rewarding it is. Excuses such as being too busy, not getting reimbursed, or not having a therapist on staff fall to the wayside.
France went through an epidemic of intravenous heroin use in the late 1990s. Overdoses took a dive after 20 percent of the country’s physicians began prescribing buprenorphine to opioid addicts. Imagine the difference we could make in the United States if its doctors could mobilize a similar effort. Keeping addicted people at arm’s length is no longer an option.
Comparing the Epidemics
So, how can we compare the first and second opioid epidemics, as well as the AIDS epidemic, with today’s crisis? The first opioid epidemic was a medical epidemic. The response was at first commercial, then medical, and then criminal. Between morphine and heroin, that crisis lasted fifty years. The next big epidemic was recreational. The response was medical as well as criminal. It lasted about twenty-five years. The response to the AIDS epidemic was medical, political, and humanitarian. It lasted fifteen years before the United States was able to mount a massive and coordinated public health response and rapidly reverse its course, and for many of those years it was an unknown disease with no known treatments.
Today’s epidemic is a medical epidemic. We are moving away from a criminal approach to a limited medical one, administering naloxone to reverse overdoses. But we fail the majority of people by sending them to treatment centers that do not use evidence-based treatment for opioid addiction. This opioid epidemic is nearly twenty-five years in the making and shows no signs of stopping. It has moved from opioid painkillers to heroin to fentanyl. The latest wave adds stimulants, such as methamphetamine, into the mix, which will be even harder to treat because we know little about the combination.
We’ve seen that epidemics don’t end entirely. They fade away and linger, meaning someone always needs help. Criminalizing drug use can help to stop the flow of an illegal substance, but punishing people for having a disorder does nothing to help them or advance treatment. The advocates for AIDS treatment knew this. They pooled their resources for the higher good and made a direct impact, saving millions of lives. In that regard, OUD is similar to AIDS. It is a disease that needs treating, and we must combat stigma and ignorance until the acceptance of treatment and the number of professionals willing to engage in it will be sufficient.
Drug epidemics come and go in cycles, but the problem of addiction never really goes away: As long as there are drugs, there will be people who get addicted. But why do some people get addicted, whereas others do not? And is anyone safe from opioids?