Most people don't know or care about the past history of addictive drugs in America. The best examples of this are the people who want to legalize all drugs and don't realize that there was a long history before regulation and that there were legal over-the-counter forms of opium and cocaine. Contrary to the Utopian way that it is portrayed today, regulation of addictive drugs occurred because of problems and not the other way around. The only way that you can think that the legal aspects of drug control created the problems rather than the drugs themselves is if you completely ignore what really happened. The quote by Osler is particularly poignant with regard to that history. The quote is from his classic text The Principles and Practices of Medicine and a chapter he wrote in that text on opiate addiction. The year was 1894. It occurs in the context of a marked increase in opium use. The isolation of morphine from opium in 1804 and the commercial production of morphine in 1826 as well as the invention of the hypodermic needle in 1855 were thought to be contributors to the opiate epidemic of the late 19th century. Although morphine had been injected into areas close to nerves previously, the hypodermic needle allowed unprecedented ability to inject morphine very close to affected nerves. Within a short while morphine injections to treat various forms of neuropathic pain were common. The statement about women being higher risk may reflect the estimated risk that women were twice as likely to become addicted to opiates from precriptions by their doctors.
The new method of treating nerve pain with injected morphine was thought to be a major advance in the treatment of chronic pain. Despite frequent injections it took some time for physicians to recognize the fact that people were getting addicted to morphine. Musto in one of his excellent texts titles a chapter: "The Belated Recognition of Addiction to Hypodermically-Administered Morphine" (1) Although that title may seem laughable today the historical mistakes have been repeated again. Just a few examples include "tamper proof" addictive medications that turn out to not be tamper proof, tramadol as a "non-addictive" option to opioids. and the idea that benzodiazepines are safe and non-addicting. All have all been disproved on a historical basis. The historical approach to addictive drugs has been a naive one - even before the era of intense marketing to physicians, massive lobbying efforts and direct to consumer advertising.
There seem to be very few people who are knowledgeable about the regulatory landscape for narcotics in the United States over the past 150 years. It is an interesting parallel to the origins of the current opioid epidemic and it rests on the principle that increasing access to addictive compounds will result in more members of society with addiction. It also has implications for the disease concept of addiction well before there was any established neuroscience. The argument in those days was whether opiate addiction permanently altered the physiology of the nervous system to the point where the need for ongoing drug was inevitable. There has been plenty of evidence to support that and the evidence has been there for a long time. As early as 1875, a German physician Eduard Levinstein collected follow up data on patients he had weaned off opiates and found a relapse rate of 75% (ref 1 p 74). In 1914, physicians at the Tombs prison in lower Manhattan estimated that it would take two months to get opiate addicts off drugs and unless they were isolated from drugs for another year the prospects for cure were low (ref 1 p 107). That sums up my experience with opioids even today. The main difference is that people are now on maintenance opioids for at least that long and get the message that they need to take these drugs for the rest of their life.
In the early 20th century, some American physicians looking to "cure" opiate addicts were fairly pessimistic about the prospects. By 1920 there was one estimate that there were a million opiate addicts in the United States. The population at the time was about 107 million people. Two options were considered at the time - indefinite maintenance on opioids and the elimination of all non-medical use. There was a relatively small number of physicians referred to as dope doctors whose practices consisted of maintaining large numbers of people in addiction by ongoing opiate prescriptions. As regulations proceeded from the belief that federal control over narcotics and prescription practices of doctors was unconstitutional in 1900 to the enactment of the Harrison Act on March 1, 1915 outlawing the non-medical prescription of opiates - there were a small number of physicians engaged in the practice of maintaining addiction. That practice was declared illegal by the Harrison Act until it was modified years later to allow methadone maintenance. The evolution of medical practice over that time was interesting. In less than a generation, opiates and cocaine went from being over-the-counter medications to being highly regulated. Medical and pharmacy practice was impacted and there were political battles along the way. Post Harrison Act there are still physicians engaged in the now illegitimate practice that are described in the popular culture in the 1950s and 1960s. Legitimate and illegitimate prescribing of controlled substances is always a fine line. In the 21st century, the main problem is the number of patients who are trying to game the system and get opioids and stimulants.
It is still illegal to prescribe addictive medications to an addict. The only exceptions are methadone and buprenorphine. Methadone prescriptions for addiction treatment can only occur in licensed methadone clinics. Buprenorphine can occur in outpatient medical practice but a special license it required and the total number of patients treated is regulated. But what about the patient who claims that they can take an addictive medication in a controlled manner? It may not be the primary addiction, but there are many patients with alcohol use disorders and opioid use disorders who believe that they have Attention Deficit~Hyperactivity Disorder (ADHD) and claim that they can take stimulant medications. There are many people with stimulant use disorders who claim that they can take prescription stimulants in a controlled manner and insist on it. How many doctors continue to prescribe these medications to patients who they know are addicted? My speculation is that there are currently millions if not tens of millions of people being maintained in addiction by physicians who think that they are being helpful as their primary motivation.
I started this post with the intent to comment on a the specific practice of buprenorphine maintenance. I commented recently on the problems with buprenorphine maintenance and why it is a far from ideal solution to the centuries old problem of opioid addiction. Since that post I have become aware of a new problem. In many areas there are very few buprenorphine prescribers and many opioid addicts. There are many excellent physicians who are addictionologists and addiction psychiatrists out there trying to make a difference. Running a buprenorphine clinic is a fairly intensive exercise that typically involves counseling and frequent toxicology screens. Many of these patients have significant medical and psychiatric comorbidity. That said, there are apparently some buprenorphine prescribers that are motivated to make a significant profit from this practice by charging patients $500 to $1,000 for brief monthly visits with additional charges for the toxicology and counseling. These charges are all in cash and in my opinion are problematic.
The problem with these charges is that they directly impact the relationship with the physician. A straight economic argument is often made. That argument goes something like this: "What would this person be spending if they were still using heroin?" That number is highly variable based on individual physiology and geographic location but a rough cost estimate would be $1200 - $5,000/month. On straight cost basis an expensive buprenorphine clinic comes in at the low end of the estimated monthly cost of daily heroin use. But that misses the point. When people are in recovery, many of them are working at low paying jobs with minimal or no insurance. They need a cost effective solution to opioid treatment and that includes buprenorphine maintenance. If they see a physician and need to pay $500-1,000 cash essentially for a prescription it will lead to immediate thoughts about why they are bothering to stay sober. It will lead to resentment toward the physician or at the minimum a loss of physician credibility. It leads to a question about physician motivation. People with addictions are no different than anyone else seeing a physician. They have to realize at some point that the physician is interested in them and helping them rather than just making a profit. There are clearly some physicians out there who don't get that point. The outcry has been palpable with a backlash on buprenorphine prescribing that is visible on several social media groups. The toal membership of these groups is over 10,000 people. Many of these people are clearly interested in tapering off buprenorphine at some point rather than life-long maintenance.
The dynamic of taking advantage of people with addictions in the US goes back to the early 20th century. The landscape has changed based on what is considered to be a legitimate prescription to people with addictions. In the 21st century we are currently operating under the premise that we may have a treatment for opioid addiction, but there are many limitations. Physicians would do better heeding Osler's warning at the top of this post. modifying his quote about hypodermic syringes to include the equivalent today - high potency opioids. In the case of people with know addictions, treatment needs to be ethical and patient focused. We have seen a rapid move to "evidence based" treatment for opioid addiction based on medications and little else. That is really not a solution to the problem of known addiction or the ongoing drug epidemics in the US.
Prevention is the best current approach to addiction.
George Dawson, MD, DFAPA
References:
1: Musto DF. The American Disease: Origins of Narcotic Control. 3rd ed. Oxford University Press. New York, 1999.
2: Musto DF. Drugs In America: A Documentary History. New York University Press. New York, 2002.
