The Lengthy, Discouraging History of Substitute Medications in Addiction Treatment

As long as addiction has existed on this planet, there has been a search for solutions to this social and health problem. In the days before addiction treatment medication existed, it was necessary to struggle through withdrawal symptoms, gradually get your life back on track, learn how to face life without chemical support and walk a narrow path day by day. In recent years, the use of one drug to substitute for the addictive substance has been gaining in popularity as it provides what appears to be a shortcut to recovery. But is it really such a great idea?

The idea that substitute medications are the best way to approach addiction treatment is now being shouted from the rooftops of every government agency, many addiction recovery facilities and most news media organizations. Funding and insurance coverage is all being funneled into this treatment path. Overlooked in this stampede is the possibility that substitute medication is perhaps not the best solution to addiction. In this report, we’re going to give you a history of the use of these substitute medications so you see for yourself how we arrived at this situation.

Centuries of Opiate Abuse

How far back do you think addiction to opiates has been documented? While opium has been used as medication for millennia, the first documentation of opium addiction shows up in the sixteenth century. According to an article in the Journal of Integrative Medicine, the Persian scholar Imad al-Din Mahmud ibn Mas'ud Shirazi recommended reducing the opium dose of an addicted person as well as substituting other medications that had fewer side effects.

A couple of centuries later, morphine arrived on the scene. In 1803, German scientist Friedrich Sertürner learned how to isolate morphine from opium, enabling this new drug to be more widely used as a painkiller. Morphine was one of the few benefits doctors could provide to Civil War soldiers with severe injuries. As a result of its frequent wartime and post-wartime use, hundreds of thousands of injured soldiers struggled with morphine addiction in the years that followed. This addiction was referred to as “the soldier’s disease.”

Opiate Addiction Spreads and the Search for a Remedy Begins

At the same time that soldiers were becoming addicted to morphine, there were many other people across the country addicted to laudanum, a solution of opium and alcohol, or smoked opium. Both laudanum and opium in other forms were easily available from pharmacists in the late 19th Century. It was prescribed as a treatment for pain, childbirth agonies, menstrual cramps, depression or what was called “hysteria.” Women could not visit saloons and drown their sorrows in alcohol like men could, but they could blot out their troubles with laudanum. From New York drawing rooms to opium “dens” out West, individuals from all social classes found themselves caught in this net.

In an effort to help all these people trapped in addiction, other drugs that were thought to be non-addictive were tried out as treatments. And this was the beginning of a constant effort to find a drug-based treatment for addiction that employed a pharmaceutical product. Paradoxically, at the same time that morphine addiction was perceived as a problem requiring treatment, it was also being used to treat alcoholism, a logic that is truly hard to follow.

Cocaine as a Solution

To relieve these people of their morphine addictions, cocaine was tried out as a treatment.

In Europe as well, cocaine was thought to successfully treat addiction to morphine, alcohol heroin and even tobacco. Sigmund Freud was an enthusiastic proponent of this treatment, using himself and his friends as test cases. But his cocaine treatment of an opiate-addicted friend only doubled the man’s addiction and led to his death.

Apparently, cocaine treatment of addiction in the United States wasn’t very successful either because in 1910, President William H. Taft reported to Congress that cocaine was the most serious drug problem the nation had ever faced. Of course, he didn’t know that heroin addiction was soon going to outstrip any problem created by cocaine.

About this continuous use of one drug to cure addiction to a prior drug, the Washington Post said: “In each case, initial enthusiasm for the ‘miracle treatment’ waned when the new drug more often compounded than relieved the problems of addicted patients. Like an invasive species introduced intentionally into an environment to combat other invasive species, each new cure eventually became a problem in itself.”

Unfortunately, this unmistakable pattern has not prevented doctors from trying this same solution, over and over, to the present day. The practice shows every sign of continuing into the future as well.

Heroin Makes the Scene

Heroin was first refined from morphine in 1874 and was thought to be a safer, non-addictive substitute for morphine. The Bayer company in Germany was optimistic that heroin would help morphine addicts recover. Or perhaps they were just considering their profits.

In the U.S., the philanthropic organization Saint James Society undertook treatment of morphine addicts who wanted to break free from their habits by offering to send out free samples of heroin through the mail. In medical journals, doctors discussed how to cure their morphine-addicted patients by switching them to heroin.

Despite the already-existing addiction problems, drugs like heroin, opium, alcohol and cannabis began to be used in cough medicine, children’s “soothing syrup,” and over-the-counter products advertised to improve diarrhea, bronchitis, pneumonia, asthma. Heroin also showed up in No-To-Bac, a remedy for addiction to nicotine.

It only took a couple of years for the first signs to show up that treatment of morphine addiction with heroin created just as many problems as the original drug did. It took a few more years to convince doctors who had been providing this treatment that treatment with heroin was a bad idea. In that time, both patients given heroin for medical problems and morphine addicts treated with heroin were turned into heroin addicts.

Drugs Start to be Controlled

As a reaction to growing numbers of addiction and overdose deaths, the early 20th Century saw a series of laws passed to control the distribution of these drugs. The importation of opium was outlawed in 1909. The Harrison Narcotic Act of 1914 nearly completely banned the use of opium or cocaine, even for medical uses. Most of the doctors who had been maintaining their addicted patients on morphine were prohibited from doing so.

However, just after World War I, New York’s City Health Department lured in heroin addicts with the promise of free heroin. They gradually tapered these patients off the drug, declared them cured and then watched 90% of them quickly resume heroin use.

In 1920, the American Medical Association announced “that heroin be eliminated from all medicinal preparations and that it should not be administered, prescribed, nor dispensed; and that the importation, manufacture, and sale of heroin should be prohibited in the United States.” In 1919, a few clinics had opened in U.S. cities to continue treating morphine-addicted patients with opiates but they were closed by 1921.

Doctors stopped prescribing these opiates but of course, those patients that could would begin to tap into the black market for the drugs they needed.

New York City and Heroin

In the 1950s, heroin was pouring into New York City via the well-known French Connection. Communities in Brooklyn, Manhattan and the Bronx suffered devastation as a result. At first, the response was to activate law enforcement measures in these areas and jail the addicted. The Narcotics Control Act passed in 1956 made the sale of heroin to minors a crime punishable by death. Hard penalties were enacted for possession as well. The only choice for withdrawal from heroin was cold turkey.

Slowly, some people began to advocate treatment for the addicted. Makeshift rehab programs sprang up. The Metcalf-Volker Act of 1962 enabled those who were addicted and got arrested to choose rehab instead of jail. Despite this growing effort to help, the heroin epidemic in New York exploded in the 1960s and spread to Washington, D.C., Philadelphia, Chicago and Detroit.

In 1964, medical researchers at what is now Rockefeller University started testing the use of a recently-developed drug, methadone, as a treatment for heroin addicts who had not succeeded after other kinds of treatment. Drs. Vincent P. Dole and Marie Nyswander found that if they gave enough methadone, their patients would not get high from using heroin. Methadone was a long-lasting drug that could be taken once a day, rather than the multiple uses of heroin required to get through a single day. In 1970, methadone clinics began to open in New York City and within a year, 12,000 people were visiting these clinics every day.

Methadone is itself a strong opioid that prevents withdrawal sickness because the person is still taking an opioid every day. It is also a drug used in medical care and a drug of abuse and subject to illicit trafficking. It has many of the same effects as heroin, morphine and opium. Those who take it properly often can get their lives back on track but what they exchange for this ability is suffering the daily deadening effects of an opioid. An addiction support group in Montreal listed the symptoms of methadone treatment as sleepiness, constipation, sexual dysfunction, sweating, weight gain, stopped menstruation, apathy and insomnia, and instructed patients how to cope with these symptoms.

The Launching of Present-Day Medication-Assisted Treatment

Giving methadone each day like this was the start of what has come to be called medication-assisted treatment or MAT. Those who advocate in favor of MAT have varying opinions—some believe that simply giving the substitute medication is treatment enough by itself. Others feel that this drug should only be given in the context of a fully-featured rehab program that includes counseling, education and other support.

In America and other countries, MAT not only refers to the use of a substitute medication, but also to the use of a long list of other drugs that are supposed to prevent cravings or block the effects of the desired drug.

In several European countries and in Canada, there are even heroin-assisted treatment programs, or HAT. Patients in these programs receive pharmaceutical-grade heroin— technically called diacetylmorphine—in daily doses and inject that drug with medical supervision. In general, this option is only offered to patients who have consistently failed after other tries at rehab. This program has been investigated in the United States but as yet, has never been implemented.

But the most ballyhooed use of MAT drugs is as a substitute for opioids: heroin, oxycodone, hydrocodone, morphine, fentanyl, oxymorphone and several others. As our current opioid crisis was building, there was a new MAT drug being approved by the Food and Drug Administration (FDA) and tested for use in addiction treatment. That new drug was buprenorphine.

Buprenorphine and Suboxone

Buprenorphine was developed as a less-additive alternative to painkillers like oxycodone and morphine. (Sound familiar?) It was hoped that this drug would have less abuse potential than earlier opioids.

It was first used in France for addiction treatment but it kept being diverted to the illicit market. In 1993, the U.S. National Institute on Drug Abuse approached the drug’s manufacturer, Reckitt, and asked if they could develop a form of this drug that was not so likely to be diverted. Reckitt developed Suboxone, a combination of buprenorphine and naloxone, an opioid antidote, the same drug used to bring people back to consciousness after an overdose. If a person being treated with Suboxone tries to also use heroin or another opioid, the naloxone in this combination precipitates withdrawal symptoms, thereby making the person quite sick. At least that is the theory.

In 2002, this combination of drugs was approved by the FDA for the treatment of opioid addiction. Over the next 15 years, its use would be broadly supported by changes in the law, insurance coverage and guidance by government and medical professionals. By 2012, nine million prescriptions for Suboxone or buprenorphine were filled.

Downsides of Substitute Medications

Drugs used to treat opioid addiction have mental and physical effects similar to the effects of the drugs causing the addictions they are treating. For example, buprenorphine and heroin are both opioids so they have similar symptoms of use.

Effects of buprenorphine include:

• Headache
• Dizziness
• Numbness or tingling
• Drowsiness
• Insomnia
• Stomach pain
• Vomiting
• Constipation,
• Feeling drunk
• Trouble concentrating

Effects of heroin include:

• Headache
• Flushing
• Suppressed breathing
• Itching
• Nausea
• Vomiting
• Constipation
• Drowsiness
• Insomnia
• Memory loss
• Trouble concentrating

For comparison, here are the effects of methadone:

• Lightheadedness
• Labored or shallow breathing
• Chest pain
• Rapid heartbeat
• Confusion
• Hallucinations
• Nausea
• Vomiting
• Diarrhea
• Stomach cramps
• Impotence
• Unstable walk
• Fainting

Mixed Opinions

Not everyone is excited about using yet another opioid to treat opioid addiction. Pharmacist and addiction expert Percy Menzies told the National Pain Report, “This is insanity. “Buprenorphine is one of the most abused pharmaceuticals in the world. We took an abused drug and we said let’s use it to treat addiction to heroin and opiates.”

About buprenorphine formulas, Charlie Cichon, executive director of the National Association of Drug Diversion Investigators, said, “…abusers found out that this was another drug that they liked. It’s not a drug that gets them on that high plain like the other drugs that they abuse. But if they can’t get that drug that they like, Suboxone is readily available and it keeps them at this mellow stage until they can get the next drug.” In other words, it allowed them to maintain their addictions on those days they couldn’t get their preferred drugs, thus eliminating any need to go to rehab.

Menzies also said, “We joke that there’s more Suboxone on the street than in pharmacies. Most of the heroin dealers are diversified now. They offer you a choice of Suboxone and heroin.”

MAT Today

At this time, both buprenorphine drugs like Suboxone, Subutex and others and methadone are being used to treat those addicted to opioids. Methadone programs often require a person to show up at a methadone clinic every day to get their dose. Patients complain that clinics are often in downtrodden parts of town and they aren’t ever able go out of town, even for a weekend, with this limitation. Buprenorphine products only require a prescription from a medical practitioner who has met the Drug Enforcement Administration’s (DEA) requirements to prescribe the drug.

Initially, buprenorphine-prescribing practitioners were allowed to treat 30 patients. Then expansion to 100 patients was permitted for those doctors who had been participating in this program for a while. Now, a prescriber can see as many as 275 patients if they meet fairly strict requirements, such as having 24-hour coverage for patients in case of an emergency and providing “access to case management services for patients, including referral and follow-up services for programs that provide or financially support medical, behavioral, social, housing, employment, educational, or other related services.”

The Advantages of MAT

Substitute medications can help a person bridge over to a sober life if they are used properly. Consider, for example, a person on a waiting list for a spot in his preferred drug rehab. If he is prescribed buprenorphine or methadone and he uses those drugs exactly as prescribed (which means no use of other intoxicants), he is protected from an overdose that could result from varying heroin potency or the inclusion of fentanyl in the drug he consumes. He stops buying heroin on the street or pills from three or four doctors so he is finally living a safer, law-abiding life and does not risk a jail sentence.

When his spot in rehab becomes available, he can start being very gradually tapered off his medications as he receives other help to learn how to maintain his sobriety as he builds a more productive, satisfying life.

The problem is that many doctors recommend the use of substitute medications for years or indefinitely. Their greater goal seems to be ensuring that a patient complies with the treatment program more than it is ensuring that the patient finally breaks free from all addictive substances and lives a 100% drug-free life.

Board-certified addiction doctor Stephen Scanlan said, “The problem I am finding in America is that doctors know how to get patients on Suboxone, but no one knows how to get them off it.” Thus, some patients may be maintained on Suboxone for years, whether it is their best interests or not.

Is MAT Really Treatment?

That’s a good question. What is the goal of medical treatment? When a cure is available, treatment should result in elimination of the health condition being treated. When a cure is not available, treatment should alleviate or manage the symptoms.

Is a cure available for addiction? Those who have had failure after failure helping the addicted back to health have apparently decided that the best they can do is maintain these individuals on drugs that are themselves 100% addictive. As the same time, there is plenty of evidence that addiction can be overcome without being maintained on these drugs.

In Narconon programs around the world, more than 40,000 individuals have said goodbye to their drug habits without relying on substitute medications. In Twelve Step programs in church basements or libraries, millions of people have found the support they need to recover their sobriety. In therapeutic communities run by charitable organizations, residents do chores, hold jobs, maintain discipline and help each other forge new, sober lives. These and other programs prove that maintenance on an addictive substance is not the only path to recovery.

While you generally only hear about a few of the substitute medications that hit the headlines, there’s actually a long list of drugs used in treatment of drug addiction. Success rates and side effects vary wildly but none of them address the underlying problems that make it difficult for some people to maintain sobriety. In essence, these drugs are substitutes for effective addiction treatment.

Substitute Medications in Development Stages

There are as yet no approved medications to treat addiction to marijuana or stimulant drugs like cocaine or methamphetamine. Researchers have hopes that a cocaine “vaccine” can be developed that would nullify the effects of cocaine and so prevent people who had been addicted to cocaine from using this drug. Currently, there are clinical trials in progress to determine efficacy and safety of this vaccine. A 2014 trial of a cocaine vaccine utilized a toxin derived from cholera that was linked to an aluminum molecule.

Is there a problem with a vaccine to treat addiction? From a CBC news article, “A vaccine won't get rid of the intense cravings an addicted person gets, but it could get rid of his or her ability to get high.” There are similar efforts to find solutions for addiction to nicotine, methamphetamine and opioids. If a person still experiences strong cravings to get high on one particular drug that is blocked by a vaccine, what will stop him from simply seeking out a different kind of drug that will get him high? Nothing.

Efforts to find medications for marijuana addiction focus on treating symptoms that arise during the person’s treatment, such as sleep problems, difficulty focusing and making decisions. But there is also work is being done to develop a drug that prevents a person from achieving the desired effect from marijuana use.

Marijuana itself is being proposed as a treatment drug for those addicted to opioids, anti-anxiety drugs like Valium, or muscle relaxants like Soma.

In Conclusion

The use of one drug as a substitute for another or to treat the symptoms of addiction will never be equal to the freedom of finally living a drug-free life. There are times that these medications can help a person normalize their lives but they should never be considered an acceptable, permanent solution to addiction when there are effective paths back to sobriety.

At this point, the medical industry, scientists and government officials have thrown their considerable weight behind the practice of using of one drug to replace the one being abused. Hundreds of studies, clinical trials and white papers endorse this practice. So surely it must be valid, correct?

It should be remembered when reading these trials and studies that when science supports the use of a drug to treat an addicted person, a pharmaceutical company is going to rake in profits for as long as that person is medicated. It would certainly be interesting to trace the funding for each one of these supporting reports and studies. Could any of them have been funded by pharmaceutical companies?

It takes millions of dollars to bring a new drug to market and pharmaceutical companies will support those millions with further investments in advertisements, seminars for doctors and lobbyists to walk the halls of Congress. Workable solutions that don’t require medications may be overlooked in this rush to profit from addiction treatment medications.