David Courtwright sees 19th-century solution to the current heroin crisis

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." ...