Famed Historian Sees 19th-Century Solution To Current Heroin Crisis

We need to focus on preventing new addictions and using the harm-reduction approach to treat current addicts.

WASHINGTON -- David Courtwright, the nation's leading historian on drug use and drug policy, has published an article in the New England Journal of Medicine arguing that physicians must heed the lessons of the 19th and 20th centuries in order to successfully combat today's opioid epidemic.

The professor of history at the University of North Florida recounts how the medical and pharmaceutical communities had successfully worked to control the epidemic on their own by reducing the number of opiate prescriptions across the country. Doctors "had succeeded through primary prevention, creating fewer new addicts as existing addicts began quitting or died of old age," he writes.

Meanwhile, Courtwright adds, a prejudice that began more than a hundred years ago has yet to be fully defeated by modern science. As the first opioid epidemic was underway, some doctors and some municipal governments engaged in what would now be called a form of "harm reduction" -- an approach known as maintenance. Where an addiction was deemed to be unbreakable, at least at that moment, doctors would maintain the supply of narcotics so that addicts would avoid withdrawal, which can be deadly, and would not resort to crime or the black market to continue using.

As Courtwright recounts, the Progressive movement strongly condemned vice, and led the push for prohibition of the non-medical use of narcotics and alcohol. The federal government carried over that mentality, with the narrow blessing of the Supreme Court, eventually prohibiting doctors from prescribing for the purposes of maintenance. That bias against maintenance continues today within the U.S. treatment system, even as advances in science have developed effective treatments such as methadone and buprenorphine. Methadone was proven an effective long-term treatment decades ago.

"The key objectives — reducing fatal overdoses, medical and social complications, and injection-drug use and related infections — are difficult to achieve if abstinence-oriented treatment is the only option available," the historian writes. "Yet that remains the situation in many places, particularly in rural locales, where officials dismiss methadone and buprenorphine as unacceptable substitute addictions."

To help tell the contemporary history, Courtwright in his NEJM article cites a Huffington Post investigation into the treatment industry from January.

"We need more and better treatment for addicts, including medically assisted recovery, and that's where your article and mine really intersect," Courtwright told HuffPost. "I made the point that general prejudice against maintenance has spilled over and exacerbated the failure to provide adequate medically assisted recovery."

The HuffPost investigation showed how Kentucky’s scarce access to such recovery methods was exacerbating the current epidemic. In 2013, the majority of fatal overdose victims in the northern part of the state had tried an abstinence-only treatment -- which bars the use of medications like buprenorphine -- before their deaths.

“What your article helped people to understand and what a lot of people still don't get, is there's a difference between an opioid addict who goes into treatment and somebody who's an alcoholic or a heavy cannabis user who goes into treatment, because the truth is that if that a cannabis user or that alcoholic comes out of treatment and relapses, they're probably not going to immediately kill themselves," Courtwright said. "Whereas the opioid addict comes out of treatment and because they've lost their tolerance and because they're overconfident about the size dose they can safely take, they're going to die.”

The historian admitted that for a long time he had thought the extent of any opioid problem would be limited to those buying heroin on the black market. When he began his research in the 1970s, he did not dream that there would be another opioid epidemic -- one twice as prevalent as the one in the early 20th century. This fall, he recalled seeing an ad for a medicine that could relieve opioid-induced constipation. The ad had aired during an NFL football game.

“I fell out of my chair,” Courtwright said. “I was just astonished. It was certainly a sign of how common the condition has become in American society.”

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