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Joseph Troncale, M.D. FASAM
Joseph Troncale M.D.

Buprenorphine, Methadone and Opiate Replacement Therapy

Part III: The Plight of the Opiate Addict from 1914 Until Now, and the Rise of S

Since the Harrison Act of 1914 and until 2001 when new laws were passed about buprenorphine, (which will be discussed later,) narcotics have been products that have been “controlled” in the sense that only physicians with an approved license could prescribe them. In fact, narcotics are poorly controlled at best, and the United States uses about 99% of the world’s output of synthetic hydrocodone. (See American Pain Society literature.)

Where did all those synthetic opiates come from, anyway? Opium and morphine were, until World War II, necessary ingredients of running a war. Troops will generally not go into battle without the hope of adequate medical care and pain relief. Germany lost its supply of opium during World War II, and just like German science was called upon to create synthetic fuel, other German scientists were called on to create synthetic opiates. The United States was working on the same ideas. They came up with a number of compounds which were moderately effective. This was the start of pharmaceutical companies getting into the pain-killer business.

Meanwhile, on the streets, the government and the medical profession had marginalized opiate addicts. There were few treatment facilities available for people with addiction, and there were essentially no treatment regimens that were standardized. It was against the law to treat opiate withdrawal with opiates.

After the Vietnam War, many veterans returned addicted to Asian heroin. The 60’s had occurred and there was a recognition that there were some serious drug problems in the United States. Drug treatment was started by some pioneers in the medical field on the West Coast such and Dr. David Smith and others. And on the East Coast, Dr. Robert DuPont, among others, began some of the first methadone programs. Treatment facilities using 12-step programs were springing up and addiction medicine began to emerge as a discipline.

Intravenous heroin users’ morbidity and mortality are 64 times greater than the general population. This is a phenomenally alarming statistic. Graduating to IV heroin use is, for all practical purposes, a death sentence. What is the typical path to heroin? The story I hear most of the time is marijuana and alcohol at age 13, pain killers by age 16, addiction to pills by age 18, inability to afford pills by age 20 and a switch to heroin, and full blown IV heroin use by age 21. Life ruined, no education, no prospects for a job, and likely early incarceration or death by overdose or drug-related violence or disease. Game over.

So what to do? Harm reduction or abstinence? What about the DEA? Well, in 2001, legislation was passed which opened the door to opiate treatment with a compound called buprenorphine. What was somewhat different about buprenorphine was that it is a partial agonist/antagonist. This means that it does some of the things a pure opiate does such as treat pain, but it also sits on opiate receptors and blocks the effect of opiates. This medication can be prescribed by physicians with a special addition to their DEA license.

Buprenorphine is a mixed bag in terms of actual results. It is a great detoxification drug for opiate dependent patients. It is important that the patient be in withdrawal because the antagonist properties of the drug will put a patient into withdrawal if given too soon. When taken as prescribed as a maintenance drug like methadone, it can allow someone to live a normal life.

So buprenorphine should be a perfect drug, correct? Unfortunately, just like any good thing, addicts and doctors have figured out ways to mess things up. On the doctor’s side, buprenorphine as a maintenance drug should be coupled with behavioral therapy and or AA, drug testing to make sure the addicted person is not diverting the drug or using other drugs while on buprenorphine, and just like other opiate prescriptions, it should be prescribed in small enough quantities to keep the patient in treatment and accountable. Addicts, on the other hand, are addicts. If in active addition they will engage in predictable addictive behaviors around buprenorphine such as stash it for a day when they need it for withdrawal from heroin, sell it; use it to get high with other drugs, etc. It is a problem when buprenorphine is paired with other substances such as benzodiazepines. This can result in respiratory depression and death.

So the opiate problem is not solved. There is no perfect drug or therapy, but it is still a certainty that the use of street heroin or synthetic opiates is extremely lethal. I have seen people use NA or AA and get clean, and I have seen people use a combination of buprenorphine or methadone and/or AA and live normal lives. The hope of change is still there. Why people make destructive choices is the question that cannot be explained except by an understanding of the power of the limbic system.

About the Author
Joseph Troncale, M.D. FASAM

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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