Where Addiction Meets Your Brain

The Neurobiology of Addiction

Buprenorphine, Methadone and Opiate Replacement Therapy - 2

Part II: Where the Harrison Act has Brought Us

In the last installment, we discussed the history of opiates, the money and power involved, and the problems with legal opiates and the Harrison Act of 1914. I would like to take up the story from the early part of the 20th century and bring us to more modern times.

After The Harrison Act was ratified, it was the beginning of the DEA and the “Controlled Substances” legislations. Again, although well meaning, this effectively drove addicted patients underground, and the black market for opiates began. What this law also did was to prohibit doctors from using opiates to detoxify opiate-addicted patients, so addicts had no place to go if they wanted to stop using opiates other than “kick.” The phrase “kicking the habit” comes from the phenomenon that opiate users who stop abruptly have involuntary leg movements as part of the withdrawal. Going “cold turkey” came from the fact that opiate dependent people get piloerection with “goose flesh” that looks like a plucked turkey skin. (But I digress…)

In any case, there essentially was no treatment for people who became addicted to opiates, and the only legal way to get opiates was through physicians. This immediately set up a game which is still being played in medical offices today, where doctors have to be clairvoyant or astute enough to know when a patient is drug seeking or in legitimate pain. It also set up a whole industry of pain pill manufacturers, pain pill doctor mills, pain pill street dealers and drug dealing cartels.

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If you haven’t noticed by now, I believe that the system is badly flawed. It is flawed because it fails to recognize the difference between addicts and non-addicts. It is flawed because it does not really regulate opiates. Current law and regulations merely create a system to be defeated by the dishonest, duped or addicted. It creates a subculture of angst, deceit and deception. It fills jails and prisons. It creates a market where there should not be a market. It creates a governmental bureaucracy that tracks down addicts and low income people who can make a profit by getting narcotics prescriptions and selling them on the street. It makes the FDA the purveyor of drugs influenced by lobbyists and drug company money. It is system that created prohibition, and prohibition failed.

There is little training in medical school about how to deal with the responsibility of a DEA license, and even less consensus on the safe and effective use of opiates. There is good scientific literature that shows that chronic opiate use for pain is ineffective. The more you take, the worse your pain experience because opiate receptors increase with use and therefore lower the pain threshold for people who need to raise their pain threshold. I am not advocating that people should suffer. I am saying that the way we treat pain is archaic and poorly administered and managed. There is less knowledge about the causes and treatment of addiction.

In the next installment, we will discuss the problems and promises of opiate replacement therapy and what could be done to improve the current system.

Joseph Troncale, M.D. FASAM, has been working in addiction medicine for 20 years. He is the Medical Director of the Retreat.
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