Six decades ago, researchers identified two transformative medical strategies that provided immense hope for managing two major public health problems. One was introducing the concept that depression originated from altered levels of brain chemicals; the other was determining that addiction to opioid drugs like heroin could be managed or even cured through treatments that targeted opioid physical dependence.
Since then, we’ve seen major success with the management of clinical depression with seven different classes of medications, 30 formally approved compounds, and several more newly identified mechanisms and medications under development. We’ve also systematically determined which medications should serve as first-, second-, and third-line treatments, recognizing that 60% of patients do not respond optimally to their first treatment and can be effectively shifted to the next line of treatment.
Perhaps just as important, mental health advocates have greatly reduced the stigma associated with depression through major campaigns involving high-profile celebrities and athletes who proudly and openly share they have “survived depression.” Of course, we still have a large percentage of patients with treatment-resistant disease. But we’ve made tremendous progress on helping countless patients manage or even overcome their illness, and have demonstrated compassion as a society towards people afflicted with this condition.
Compare this to how we have managed opioid use disorder, which is widely recognized to be a national crisis. Against the backdrop of profound growth and discovery for depression, we only have four medications currently on the market to treat opioid use disorder or its withdrawal. Methadone was demonstrated to be effective for opioid use disorder approximately 60 years ago, yet it took 7 years for it to be approved and another 13 years before a second medication, the opioid blocker naltrexone, was approved. Buprenorphine, a long-acting opioid similar to methadone, was not approved until 2002. During this time, a derivative of methadone called levo-alpha-acetylmethadol (LAAM), was approved but removed from the market due to life-threatening cardiac events.
These medications were all iterations on the same concept: that administration of a long-acting drug that worked on the opioid receptor could be used to manage withdrawal (methadone, buprenorphine, LAAM) or prevent resumption of use (naltrexone). It was not until 2018 that a totally new mechanistic strategy was formally approved for the treatment of opioid withdrawal, when lofexidine (Lucemyra) became available. During this time, more and more people have died from or become addicted to opioids, with estimates suggesting more than 7 million people in the U.S. are suffering with opioid use disorder.
Why has there been such modest medical advancement, investment, or transformation in the field of opioid addiction compared to other forms of mental illness? Why, despite large international campaigns such as “Let’s Talk” and “Do Your Share” to address stigma surrounding other mental health conditions, have we not seen such coordinated efforts for addiction, a condition for which “surviving” is also worthy of celebration? Why are the preponderance of addiction treatments targeting the same brain target? This prevents patients with addiction from moving to possible second- or third-line treatment options.
I don’t know the answers to these questions, but it seems likely that stigma towards people who use drugs plays a role.
Although methadone was successful pharmacologically, it faced rigid scrutiny and regulations that complicated its implementation. Even now, after five decades of experience, it can still only be prescribed from specialty treatment providers.
The addiction treatment field is isolated from other medical programs, presumably to protect patient confidentiality, which leaves it highly decentralized and confusing. Many patients avoid discussing their addictions until they are too severe to conceal, at which point they are often very complicated to treat, particularly for a field with too few options.
This stigma also may extend to industry and venture capital, which appear to have insufficient interest in developing medications for addiction, despite its deadly nature. It is also worth noting that opioid use has arguably the most well-developed treatment infrastructure of the substance use disorders; no medications have been formally approved for addiction to cocaine, methamphetamine, or cannabis.
January 2025 marked the first ever Substance Use Disorder Treatment Month, as designated by the Substance Abuse and Mental Health Services Administration. Growing the number of patients receiving treatment for addiction should be a priority for a country that continues to grapple with unprecedented rates of addiction and fatal overdoses. Americans have lost more than 1 million parents, partners, friends, and children to fatal overdoses over the past two decades, and the loss of those loved ones has irreparably altered the lives of those who fought this illness alongside them.
We can do better. We know that because the field of depression has provided us with a roadmap.
Our treatments work but are challenging to access, and more options are needed for those who are not responding. There are more mechanisms to be discovered and more medications to try. Substance use treatment should be integrated into, rather than isolated from, the general medical system. Industry incentives should be optimized to support research investment, and insurers should be incentivized to provide medication and care coverage. And we should be openly and proudly celebrating loved ones who have survived addiction.
We have invested 50 years into our current treatment strategy yet continue to suffer unprecedented consequences. It’s high time to reduce the barriers to existing treatments and to commit to the investment and identification of new solutions.
Kelly Dunn, PhD, MBA, is director of the University of Maryland School of Medicine’s Kahlert Institute for Addiction Medicine.
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