History of Opioid Addiction in America: Why the Treatment System is Divided

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By Peggy Gemperline RN, BSN, MBA, Vice President, Residential Treatment Services, Pinnacle Treatment Centers

Few treatment professionals possess combined experience with abstinence-based residential and outpatient treatment for substance use disorders as well as knowledge of medication-assisted treatment (MAT), particularly methadone maintenance. Why?  These are different worlds, with different languages, belief systems and rules.

Most professionals who have worked in the field for any length of time were taught the “disease model” of addiction and a 12-step approach to ongoing recovery support.  Early medical and psychiatric origins of residential treatment were rooted in the use of sanatoriums and “inebriate homes” which isolated patients from day to day life to allow a complete focus on recovery.  A variety of ancillary interventions were also deployed, generally devoid of any evidentiary basis, such as hydrotherapy and even forced sterilization in the case of female alcoholics.1

The founding of Alcoholics Anonymous in 1935, its subsequent rapid spread, and the many other 12-step programs that followed were among the first to prove the efficacy of complete abstinence from alcohol and other drug use.

Opioid use disorder (OUD) had a rather different journey. During the 19th century, opiate use was widespread in the U.S.  Medicines and tonics containing derivatives of the opium poppy were sold over the counter without a prescription.  Among the biggest consumers were women, including working class wives of farmers as well as upper class women, men, physicians, pharmacists and others able to purchase the many tonics and “cures” advertised to treat a multitude of maladies or promote wellbeing. Even after the development of heroin and its use in medicines manufactured by the Bayer company, there was no illegal opioid market that flourished among illicit sub-cultures, but rather opiates could be used in the privacy of one’s own home.2

Perhaps this is why the first efforts to treat opioid addiction in America followed a medical model. Mostly private practitioners and early psychiatrists who observed rapid, tapered withdrawal, and stays in asylums or inebriate homes resulted in a 90 percent or greater relapse rate.

The first opiate replacement clinics (morphine replacement clinics) were opened in 1912 and operated in the northeast and the south until the last one closed in Memphis in 1925.  The same US Treasury Department that enforced prohibition laws was responsible for increasing aggressive enforcement of the Harrison Narcotics Act; laws that followed prompted those closures and led to the rapid growth of the illicit opioid market.

The opioid addiction problem, known as the soldier’s disease after the Civil War – when the invention of the hypodermic needle allowed for widespread use of injectable morphine for battlefield injuries.  (Incidentally the inventor of the hypodermic recommended morphine injections for treatment of menstrual cramps and other ‘female problems.’ Subsequently, his wife became the first woman to die of an overdose of intravenous morphine).  As the opioid addiction problem grew with the end of each war that followed, medical professionals initiated the morphine replacement clinics as a harm reduction effort.  But what they found instead was that patients’ lives improved quite unexpectedly. People re-entered the workforce, families were reunited, and communities were healthier. Sound familiar?

So that leads us back to our initial point: the opioid treatment program (OTP) world and residential treatment world are different, evolved separately with differing philosophies, languages, and belief systems.  If the opioid overdose epidemic has taught us nothing else, it is that bifurcation is really no longer appropriate.  Undisputed research confirms that opioid agonist medications, i.e. methadone, buprenorphine, are best practice for the treatment of OUD and drastically reduce overdose fatalities.  In this new era of treatment of opioid use disorder, the American Association of Addiction Medicine (ASAM) has provided guidance on patient placement criteria for the appropriate level of care when treating addictions. This applies to those in need of treatment for opioid use disorder as well, although the entirety of the US treatment system may not, as of yet, caught up to that fact.

We know that 80 percent of fatal opioid involved overdoses in the US also involve at least one other substance, whether legally prescribed or purchased or illicitly obtained.  A new research study conducted by the Veterans Health Administration indicated alcohol was the most common substance among veterans who were opioid overdose decedents, while medications prescribed to treat mental health conditions were most common among women and individuals with serious mental illness. This presents a problem for the classic OTP focused solely on treating opioid use disorder, as many patients are also addicted to and using other substances. Those of us who have worked in residential treatment understand that detoxification and treatment for moderate to severe addiction to benzodiazepines or alcohol is rarely safe at home.  However, residential treatment centers generally won’t accept patients who are being treated with methadone.  Therefore, in order to receive the appropriate level of care, many of these patients would be compelled to be tapered from methadone.

At Pinnacle, we understand that methadone maintenance patients are among the most likely to have long-term recovery success. We have been helping methadone maintenance patients sustain and improve their chance at recovery success by offering them residential treatment, followed by partial hospitalization (PHP) and sober living opportunities. We want to build upon these efforts and allow patients who enter treatment through any door to receive the appropriate level of care.  Our system offers a continuum of care that is sufficiently comprehensive to make this possible, no matter the unique circumstances of each individual client.

I’m so excited to be a part of an organization at the forefront of comprehensive quality addiction treatment, informed by science and offered within a full continuum care. I know that together, we will continue to save a lot of lives!

Sources

[1] Slaying the Dragon, William White. 1998

[2] Niki Miller. ( 2014). “The Promise of Gender Mainstreaming Miller.” In Drugs and Alcohol Women Network: Promoting a Gender Responsive Approach to Drug Addiction. United Nations Office on Drugs and Crime, Interregional Crime and Justice Research Institute: Turin, Italy.

Kandall, S R. 1996. Substance and shadow: women and addiction in the United States, Cambridge, MA: Harvard University Press.

Niki Miller. ( 2014). “The Promise of Gender Mainstreaming Miller.” In Drugs and Alcohol Women Network: Promoting a Gender Responsive Approach to Drug Addiction. United Nations Office on Drugs and Crime, Interregional Crime and Justice Research Institute: Turin, Italy.

White, William L., 1947-. Slaying The Dragon : the History of Addiction Treatment and Recovery in America. Bloomington, Ill.: Chestnut Health Systems/Lighthouse Institute, 1998.