The history of treatment for substance abuse is a long one. The types of medication assisted treatment we use today have histories dating back to the 1930s. Over the course of the 1900s two types of treatment developed. One being based on total abstinence and the other focused more on harm reduction or maintenance.
Abstinence Based Treatment: Definition and History
Abstinence based treatment is treatment based on the complete cessation of substance use. Any use of substances is considered a relapse and is dealt with accordingly. Abstinence based drug and alcohol treatments got its start in mid 1900’s and is better known as the Minnesota Model.
The History of Abstinence Based Treatment
The creation of AA in 1935, followed by the publishing of its primary text, “The Big Book,” coupled with several medical advances slowly led to the acceptance of alcoholism as a disease, which was a precursor to the Minnesota Model.
In the late 1940’s, the addiction rehab industry had no idea how to handle the population of alcoholics. They were most often jailed, put in institutions for the mentally ill, or left to the fate of their addictions. However, at the same time, Alcoholics Anonymous’ membership had grown to over 90,000 and it had been working.
The Minnesota Model of addiction treatment was created in a state mental hospital in the 1950’s by two young men. Neither had prior experience working with addicts and alcoholics.
The model would become the basis for over 90% of addiction treatment rehabs today by first spreading to a small non profit organization called the Hazelden Foundation, and then throughout the country. The key elements of the abstinence approach was the blending of professional and trained nonprofessional (recovering) staff around the principles of Alcoholics Anonymous.
There was an individualized treatment plan with active family involvement in a 28 day inpatient setting and participation in Alcoholics Anonymous, both during and after treatment. The education of patients and family about the disease of addiction made this a busy program from morning to night, seven days a week.
Medication Assisted Treatment (MAT): Definition and History
Medication Assisted Treatment for opioid addiction is the use of medications in combination with counseling and behavioral therapies. MAT is primarily used for the treatment of addiction to opioids, such as heroin and prescription painkillers. The prescribed medication in MAT operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused substances. Unlike abstinence based treatment, the therapeutic definitions of progress and success are determined by small improvements and not in staying totally abstinent. For instance, if a drinker normally has 10 drinks, if they only have 5—that is successful implementation of the harm reduction treatment/MAT.
The History of MAT
For the purpose of keeping this blog focused we are going to solely focus on the history of medication-assisted treatment for opioid addiction.
Opioid addiction first emerged as a serious problem in the United States during and after the Civil War when opioids were prescribed to alleviate acute and chronic pain, other types of discomfort, and stress. By the late 19th century, probably two-thirds of those addicted to opioids were middle-and upper-class white women, attributed to “the widespread medical custom of prescribing opiates for menstrual and menopausal discomfort, and the many proprietary opiates prescribed for ‘female troubles.’” Civil War veterans who were addicted by medical procedures composed another group, but their numbers were dwindling. By 1900, an estimated 300,000 persons were opioid addicted in the United States.
During the late 19th and early 20th centuries, U.S. society generally viewed this kind of addiction among women and disabled war veterans sympathetically—as an unfortunate medical condition—and treated these groups with tolerance and empathy, particularly because neither group presented major social problems.
Doctors usually prescribed more opioids for these patients, and sanatoriums were established for questionable “cures” of the resulting addictions. The chronic nature of opioid addiction soon became evident, however, because many people who entered sanatoriums for a cure relapsed to addictive opioid use after discharge.
In the 1920’s, an increase in crime related to the acquisition of illicit opioids was reported in cities throughout the country. In 1929, Congress appropriated funds to establish two new treatment facilities, initially called “narcotics farms” in Fort Worth, Texas, and Lexington, Kentucky. The Lexington facility, which opened to patients in 1935, was renamed the U.S. Public Health Service Narcotics Hospital in 1936.
These institutions detoxified patients with opioid addiction who entered voluntarily, and they also served as hospitals for prison inmates who had opioid addictions and were legally committed through a Federal court. The prescribed stay was about 6 months, although some patients stayed longer. Prisoners could stay for up to 10 years. These hospitals offered social, medical, psychological, and psychiatric services in addition to detoxification and had a low patient-to-staff ratio (about 2 to 1), but the atmosphere was described as prisonlike. Two major follow-up studies showed the program to be a failure.
The next major change in opioid addiction during World War II as many European immigrants moved from crowded cities into areas with pre-existing abuse problems and then acquired the addiction. This shift also led to a hardened attitude when it came to those with addiction disorders.
The increase in heroin addiction in New York City after World War II led, in 1952, to the establishment of Riverside Hospital for adolescents with addiction disorders, this program also proved to be a failure. A follow-up study in 1956 showed a high post-treatment relapse rate (e.g., at least 86 percent of patients admitted in 1955), and the Riverside facility was closed in 1961
Later in the 1960’s, heroin use among middle class, young white Americans, was on the rise as was addiction related crime. By the 1970’s, the US military involvement in Vietnam was also having an effect. The New York Academy of Medicine recommended, in 1955 and again in 1963, that clinics be established in affiliation with hospitals to dispense opioids in a controlled manner to patients addicted to illicit opioids. In 1956, the AMA advocated a research project to investigate the feasibility of dispensing opioids in an OTP (opioid treatment program). In 1963, the Kennedy Administration’s Advisory Commission on Narcotic and Drug Abuse also recommended research to determine the effectiveness of outpatient OTPs’ dispensing of opioids to people addicted to opioids.
Then there was methadone.
Short-acting opioids (morphine etc.) were eliminated as options for maintenance therapy, so research focused on methadone. Methadone appeared to be longer acting and more effective when administered orally. It also was selected on the basis of observations of its use in patients withdrawing from heroin and as an analgesic in the experimental treatment of pain with medication-assisted treatment.
In 1964, technology was not available to measure blood levels of heroin, morphine, or methadone to assess duration of action. Proof of the efficacy of methadone maintenance treatment depended on observation and recognition by researchers. In general, the team found that patients’ social functioning improved with time in treatment, as measured by elimination of illicit-opioid use and better outcomes in employment, school attendance, and homemaking. Most patients were stabilized on methadone doses of 80 to 120 mg/day. Most patients who remained in treatment subsequently eliminated illicit-opioid use.
The 1980’s and 1990’s
By the 1980’s, an estimated 500,000 Americans used illicit opioids (mainly heroin), mostly poor young minority men and women in the inner cities. Addiction became not only a major medical problem, but also an explosive social issue. By the end of the 1990’s an estimated 898,000 people in the United States chronically or occasionally used heroin and the number of those seeking treatment was approximately 200,000.
Then, there was naltrexone. In the early 1980’s, the National Institute on Drug Abuse (NIDA) completed initial testing of naltrexone to treat opioid addiction, and FDA approved naltrexone for this use in 1984. In 1995, naltrexone received FDA approval as a preventive treatment for relapse to alcohol use among patients dependent on alcohol.
Some opioid treatment providers have found that naltrexone is most useful for highly motivated patients who have undergone detoxification from opioids, and need additional support to avoid relapse or who desire an expedited detoxification schedule because of external circumstances. Naltrexone, may benefit some patients in the beginning stages of opioid use and addiction. Other patient groups frequently have demonstrated poor compliance with long-term naltrexone therapy, mainly because naltrexone neither eases craving for the effects of illicit opioids when used as directed nor produces withdrawal symptoms when discontinued.
In 1997, a National Institutes of Health (NIH) consensus panel called for an expansion of methadone maintenance treatment. Since then methadone treatments, suboxone treatments, and naltrexone treatments have all be on the rise as MAT. Many rehabs today are utilizing MAT while coupling it with behavioral therapy.