Where Addiction Meets Your Brain

The Neurobiology of Addiction

Buprenorphine, Methadone and Opiate Replacement Therapy

Part 1: Lessons From History

One of the more controversial issues in addiction medicine is the practice of opiate replacement therapy or ORT. I think it is important to understand the history of ORT if we are to begin to understand how it should or should not be used.

It did not take human beings long to figure out that there is money and power in opiates. The poppy was known four thousand years ago in Mesopotamia as the “joy plant.” Opium eventually found its way around the world, and by the time there were trade routes, opium became a cash cow for the nations that could import and export it. The European nations created new markets for opiates and while actual slavery was in existence, new “slaves” were being created to maintain the opium trade. (The root word for addiction is the Latin work “addictus” which translates “slave".)

The opium wars of the nineteenth century in China were about Britain and other first world countries being able to have ports through which opium could be exchanged for money. China wanted the opium outlawed because it was bringing so many Chinese to poverty and misery, but Britain wanted the money to flow. So the first “war on drugs” actually was fought about 150 years ago resulting in Britain maintaining control of Hong Kong.

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Around the same time, it was discovered that opium could be dissolved in alcohol since it was not soluble in water, and the compound named laudanum was produced in Europe. Morphine was also synthesized at this time. Laudanum and morphine were big hits in the medical world in the nineteenth century. Whatever your ailment, morphine, laudanum and cocaine were medicines almost guaranteed to help you feel better.

During the Civil War in the US, war casualties that survived death were given opiates. Patients of all kinds with practically any ailment were candidates for opiates. By the time the twentieth century rolled around, there were substantial numbers of people addicted to opiates in the US. However, since opiates were legal, there were numbers of opiate clinics that would maintain individuals on opiates. No problem.

Enter the governments of the world as there is a movement internationally to restrict the opium trade. The response of the US and the Progressives under Woodrow Wilson’ was to pass the Harrison Act of 1914, which was the first “tax and regulate” law of opiates. The unintended consequences of this law were vast and complicated. We continue to live and die with this law and its regulations today. The most important consequence, in my opinion, is that, like prohibition of alcohol, opiates went “underground,” creating a new class of addict/criminal that has cost society billions of dollars in law enforcement, incarceration, illegal activities and cartel formation and not the least of which is suffering for addicts who are pawns in a much larger game.

In the next installment, I will discuss what has happened over the twentieth century and what the pros and cons of ORT look like.

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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