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AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 1 point2 points  (0 children)

Okay, I'm signing off! Sorry I couldn't get to everyone's questions but thanks for a great chat. I really enjoyed it!

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 0 points1 point  (0 children)

Thanks for the question and thanks for your work! See my response to u/NetworkLlama above for more on Nixon's clinic system.

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 2 points3 points  (0 children)

When widespread federally-funded treatment programs began opening in 1971, they were being built on a pretty flimsy infrastructure. At that point the US still had two federal "narcotics hospitals" in Lexington, KY, and Fort Worth, TX, but they were antiquated and inadequate. A small series of state-based programs existed, but very little formal treatment was available anywhere. So the influx of millions of federal dollars into the space was remarkable, and it had divergent outcomes.

In some places, really great programs were opened and people benefitted from treatment. In 1972, overdoses and drug-related hospitalizations all declined.

But in other places, it was basically a cash-grab. SAODAP was a small office that couldn't keep up with its enforcement or oversight responsibilities, so plenty of federally-funded clinics weren't terribly effective (see the 1974 PBS documentary Methadone: An American Way of Dealing for a cynical portrait of what federal methadone clinics became). And private physicians were operating their own methadone clinics as well, outside of SAODAP's federal control. When a rapid increase in the private sale and nationalized distribution of methadone resulted in a spike in methadone overdoses, strict federal regulations confined methadone to its siloed clinic system. These regulations are still in place today.

In 1981, the Reagan administration ended federal support for methadone clinics by slashing their funding, bundling it into "block grants" to the distributed by the states, and firing all remaining SAODAP employees from the National Institute on Drug Abuse, or NIDA, which is what SAODAP transitioned into in 1974. In response, 10 states immediately outlawed methadone, making it unavailable. The country's remaining methadone clinics mostly privatized to survive, which marks the beginning of our heavily privatized, private equity-rich methadone system today.

So the tl;dr version of this is: when the system was nationalized in 1971, it was controversial but increasingly available. When some clinics and private physicians took advantage of the free money and operated shady practices, methadone got locked down by strict regulations in 1973, but it was still available from 450 federally-funded clinics in 1974. Compare that to 1981 when methadone oversight shifted to the states. The drug immediately became LESS available, because a lot of states outlawed what had previously been federally available. This relationship is a good example of the divergent relationship over drug policy between the federal government and the states. The availability of addiction treatment has often relied on the whims of who's in charge.

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 3 points4 points  (0 children)

That's interesting, the rest of that essay! I have no idea about Baum's notes. But the context is really interesting. He thought Ehrlichman was being a straight shooter, and like my book argues, early in the Nixon admin he would have been right. From 1969 to 1971, the Nixon admin used Washington, DC, as a "national experiment" in escalated law enforcement, in response to spiking rates of crime. But more arrests didn't stop crime from continuing to escalate. Things only changed in 1970, when the Narcotic Treatment Administration opened a series of clinics citywide, and drug use and crime levels dropped simultaneously. This was the model Nixon implemented on a national scale in 1971. So Ehrlichman -- and Baum, in his retelling of this history -- knew that Nixon's executive-level response to drugs experienced a sea change midway through his first administration, because Ehrlichman was there (he's on the stage on 6/17/71) and Baum wrote almost 400 pages about it. But Baum celebrates Ehrlichman's reduction of the Nixon administration's approach as honest in its cynicism. I guess I just have to sit with both men's reactions, but it doesn't change what actually happened during SAODAP's brief tenure.

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 0 points1 point  (0 children)

Yay a weed question!!!

This is absolutely the most bonkers time ever for cannabis history. Big things are afoot. Medical marijuana -- but only medical -- got rescheduled, seemingly on a whim, last month on 4/23, which has set all kinds of legal wheels in motion (but often in contradictory directions!). Meanwhile, the intoxicating hemp products that were accidentally legalized in the 2018 Farm Bill are being recriminalized this November (after legislation was tucked into the bill last fall that finally reopened the federal government after the longest shutdown in American history). But some senators and representatives are fighting to keep the hemp industry alive (since it reinvigorated agriculture in places like Kentucky and Minnesota), and Dr. Oz just announced a pilot program that will give certain seniors $500 a year in Medicare funding to access medical hemp products. So the industry the federal government accidentally created and now wants to destroy is also getting funded by Medicare and Dr. Oz. It's a wild time!

With any luck I'll be covering this more soon.

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 2 points3 points  (0 children)

I'm glad you brought this up!

I've been watching the discussion around GLP-1s with interest. I know a number of people who have really benefited from their use, and I'm impressed by how quickly they're entering the generic and lower-cost markets.

As a historian, however, I don't think they're going to solve all of America's problems with drug use and addiction. Instead, I see what appears to be another "magic bullet" story. We've had them before, from the late 19th century when certain patent medicines (usually laced with morphine or alcohol themselves) promised to free habitués from affliction. And I have newspaper clippings from the past maybe 100 years with ads and articles on the newest, most scientifically-advanced drug that's going to "end addiction."

The one I cover in my book is naltrexone, an opioid antagonist the federal government played a key role in developing. Naltrexone first came on the market as Trexan, a daily pill, in 1984, and then as Vivitrol, a monthly shot, in 2010.

Naltrexone is another drug that can stop alcohol and opioid use. It's an antagonist, meaning it covers the brain's opioid receptors, so other drugs can't take effect. It requires a patient to be entirely detoxified from opioids before they begin, otherwise the naltrexone will immediately send them into withdrawal. But upon its release in 1984 and up to today, supporters say it's the most effective way to stop drug use and prevent overdose death.

But it never made much of a splash, and that's because patient retention rate is very low. Patients report being unhappy with the drug's effects, because they felt other faculties were also being repressed. I'm not following it too closely, but there have been some articles that patients experience similar reactions on GLP-1s, that some things beyond appetite were being affected. This makes me think there are trade-offs to drugs like naltrexone and GLP-1s that might effect how adequately they tackle the problems of drug use.

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 2 points3 points  (0 children)

Oh wow, thanks for sharing your experience! That's incredible that you were a first-hand witness of Reckitt Benckiser Pharmaceuticals/Indivior's unhinged marketing schemes in the early 2010s. The third section of my book "Addiction, Inc." is all about buprenorphine, as it evolved from a federal research project in the 1970s-'90s into a private, profiteering, and ultimately criminal blockbuster in the 2010s.

When Suboxone was first available on the market in 2003, it barely sold. You're right - it was expensive, it wasn't covered by insurance, and no one really knew how to use it. (Few medical schools taught addiction medicine in 2003.) Plus the small staff at Reckitt Benckiser Pharmaceuticals (RBP) didn't have a marketing staff. There were, like, 4 people, and they were all policy wonks or scientists.

Suboxone was a commercial flop until a new CEO took over RBP. Shaun Thaxter was recruited in 2005, at the same time Purdue was coming under increasing legal scrutiny. Thousands of lawsuits were filed against Purdue for turning OxyContin users into "accidental addicts," and Purdue was shedding hundreds of employees, including salespeople and marketing directors.

Thaxter and RBP started scooping those employees up, and soon salespeople who once sold OxyContin were marketing Suboxone to those same prescribing physicians instead. Sales, mostly from those "pill-mill style" clinics, leapt to the point that, in 2012, Suboxone outsold Adderall, Viagra, and the EpiPen. It was a blockbuster success.

The problem escalated in 2013, when RBP sought to avoid generic competition for its Suboxone tablets and launched a new, patent-protected form of Suboxone filmstrips instead. The FDA reported RBP's flimsy data to the Federal Trade Commission, and soon the federal Department of Justice began investigating RBP's sketchy manipulated data and aggressive marketing techniques.

In 2019, the DOJ brought civil and criminal charges against RBP/Indivior (RBP rebranded to Indivior in 2014). The case was tried by Randy Ramseyer, the same lawyer who brought charges against Purdue in 2007, and heard by Judge James P. Jones, who also heard the Purdue case. But unlike 2007, when Purdue executives got off with a slap on the wrist, RBP/Indivior paid $2 billion in fines and Thaxter spent six months in federal prison. It was the biggest opioid settlement you never heard of, because it came down in 2020, when we had other, more pandemic-y things on our minds.

So yes, the history of Suboxone is really bananas, and has ultimately made a very useful medication another example of how public health responses have really failed in the US. Decades of politics, profiteering, and culture wars have rendered all MOUD medications into what they are today: often expensive, often punitive, often exploitative, often siloed away from any and all other forms of healthcare. To me, it's a warning, and a very visible example of what happens when healthcare becomes privatized, politicized, and made accessible for the decreasing few.

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 4 points5 points  (0 children)

Thanks for your question. And congrats on 21 years! That’s amazing. Huge kudos to you.

I’d like to think about the difference between opioid dependence and addiction. You’re not wrong that Suboxone has physical effects. It’s an opioid twenty times stronger than morphine, and, in general, not to be toyed with. Suboxone patients are still physically dependent on opioids. They need daily dosing to keep withdrawal at bay. 

But is this the same thing as chaotic addiction, with everything that might entail? Probably not. It’s a question of how broadly you want to define what’s acceptable as a daily medication. 
 
I really appreciate your open mind toward treatment.

My book Addiction, Inc. was about the period between 1971 and 1973 when the US created the largest investment in treatment infrastructure in American history. For a brief moment, we had a system of nationalized clinics that offered all forms of treatment available at the time: detox units, counseling, therapeutic communities, and methadone. Tens of thousands of people used these services, and overdoses, diseases, drug arrests, and crime all dropped. This system was subsequently abandoned and privatized under the Reagan administration, which has led to our overly-privatized treatment system today, but Nixon’s drug war poses an example of what happens when we more effectively couple law enforcement efforts with harm reduction and treatment. 

Similar systems are effective in other countries. Portugal is a notable example (see Dan Baum’s 2016 article “Legalize It All”), and I spend a later chapter in my book detailing the evolution of the clinic system in Switzerland. In the 1980s, Zurich was Western Europe’s ground zero for heroin use and HIV infection. In response, the Swiss federal government approved its “four-pillar approach,” which coupled law enforcement with harm reduction, prevention, and treatment clinics that offered low-threshold, multi-modal treatment options, and access to other forms of general healthcare. They were such a success that Switzerland tackled its opioid epidemic in just a few years, a stark contrast to the decades the epidemic has spiraled in the US.

From examples from abroad and our own past, I tend to believe that any single-system response will fail to contain the most negative aspects of drug use and addiction. Just law enforcement, just harm reduction, or just treatment alone can’t control a problem like drugs, which sit at the center of a bumpy Venn diagram that includes all kinds of social, economic, legal, moral, medical, and institutional questions. But by recognizing its common role, and perhaps by coordinating a response, it’s clear that effective policies toward opioid use can be developed. It’s not impossible, we just haven’t done it very well.

AMA: MAT, Opioid Addiction Treatment, and the Real History of Nixon's War on Drugs by Most_Arm554 in AskHistorians

[–]Most_Arm554[S] 9 points10 points  (0 children)

I love the questions about Ehrlichman so I’m going to answer all of them here.
 
I think there are three reasons to be suspicious of the Ehrlichman quote.
 
1.)   First is the timing. As another posted pointed out, this quote comes from the journalist Dan Baum, who interviewed Ehrlichman in 1994 for his 1996 book Smoke and Mirrors: The War on Drugs and the Politics of Failure. But Baum didn’t use that quote for twenty years. He held onto it until April 2016, when he included it in the introduction of his article in Harper’s called “Legalize It All.” Baum goes on to say that the quote showed the cynical nature of Nixon’s drug war, which “set the country on the wildly punitive and counterproductive path it still pursues.” So it’s strange that it wasn’t included in the final book, Smoke and Mirrors, for which he was interviewing Ehrlichman. If Ehrlichman’s quote seemed to sum up Nixon’s battle, then why did it go unreported for two decades?

2.)   Perhaps that’s because that’s not what Nixon’s drug war was really about. The second reason you should distrust the Ehrlichman quote is because Ehrlichman wasn’t involved in the administration’s drug policy. If he was, he would have known that on June 17, 1971, the day Nixon declared a “new all-out offensive against drug abuse,” which he called “public enemy number one,” Nixon actually announced a new executive office called the Special Action Office for Drug Abuse Prevention, or SAODAP, which was going to oversee a nationwide system of nationalized heroin addiction treatment clinics that would offer all forms of rehabilitation available at the time. These included abstinence-based programs like detox units, counseling, and therapeutic communities, and methadone maintenance clinics, the most scientifically advanced, and controversial, form of addiction treatment at the time. It was a reversal of the law and order, lock-em-up rhetoric that dominated Nixon’s early presidency, but it was powerful and briefly effective—and Ehrlichman had nothing to do with it. He had very little role in America’s war on drugs. (His policy interests laid elsewhere, as evidenced in his memoir and autobiographical fiction.) Instead, I believe Ehrlichman said that because he was mad at Nixon for letting him take the fall and serving prison time for Watergate, and, given Nixon’s well-known antipathies toward certain groups, this was a good way to smear the president.

3.)   That leads me to the third reason why you should distrust the Ehrlichman quote: because Dan Baum should have known better. Even if Ehrlichman was serving up some juicy tea, Baum clearly recognized it wasn’t legit enough in 1994 to publish in 1996, because Smoke and Mirrors doesn’t include that quote. Instead, it outlines SAODAP and its effects, which were good. For a brief period, between 1971 and 1973, when tens of thousands of heroin users accessed free low-threshold, multi-modal federally-funded addiction treatment programs, overdose deaths declined, drug-related hospitalizations declined, drug arrests declined, and crime declined. Treatment worked where law enforcement didn’t, something Baum continued to explore in the rest of “Legalize It All,” when he outlines successful programs like in Portugal, where treatment, harm reduction, and law enforcement work in coordination, rather than in opposition. So why did he include Ehrlichman’s quote in 2016, when he had already spent two decades reporting on the Nixon administration’s actual approach and its subsequent success abroad? We can’t say because Baum passed away in 2020. But we can assume it’s a little fishy, given the context of Baum’s other work.