How the heroin epidemic evolved today’s addiction treatment landscape

In the face of the ongoing opioid epidemic, society has been compelled to reassess and reshape its approach to addiction treatment. While the crisis continues to devastate communities, significant strides have been made in the medical and psychological fields to address and combat the challenges posed by opioid addiction.

In this blog, we’ll explore the evolution of heroin and opioid addiction treatment, highlighting the intersection of compassion and science in the quest for more effective recovery models.


Heroin epidemic- A brief history

Although the US recently came out of the previous opioid epidemic (1999-2021), the illegal opioid markets experienced fluctuations way before the prescription opioid misuse era. Surges in heroin usage occurred after World War II and in the late 1960s, with interventions containing the problem. This included the early use of methadone and measures like the Turkish poppy ban and dismantling of the “French Connection.”

In the mid-1990s, there was a revival of heroin, driven by those transitioning from prescription opioids to cheaper but riskier black market alternatives. This was largely due to a huge increase in opioid prescriptions. When users with dependencies couldn’t obtain prescriptions, it would lead them to the illegal market. This shift altered user demographics, significantly increasing heroin use and demand.

Then, in 1999, the US entered the Opioid Epidemic. Sadly, between 1999 and 2021, around 645,000 people died from opioid overdoses in three separate waves.

The first wave in 1999 was largely due to the over-prescription era mentioned previously. Then, in 2010, there was a sharp increase in deaths related to heroin. The third wave started in 2013, with a significant surge in fatalities involving synthetic opioids, especially illicitly made fentanyl. Illicit fentanyl, often mixed with heroin, fake pills, and cocaine, continues to be a dynamic problem.

Despite efforts to address the opioid crisis, the challenges persist, and understanding the historical context provides valuable insights for developing effective future strategies.

So, what have we learned from history?


How heroin and opioid epidemics have shaped how we treat those with addictions

In this section, we take a closer look at how past tragedies have shaped the way we treat people with heroin or opioid addictions:

The introduction of Medication-Assisted Treatment (MAT)

Earlier views on addiction treatment often leaned heavily towards abstinence-only models, like the Minnesota Model. However, opioid and heroin epidemics throughout history have shifted the paradigm, challenging the notion that recovery must be strictly abstinent.

MAT is now recognised as an evidence-based approach that significantly improves outcomes for people suffering from OUD.

The understanding has evolved to view MAT as a valuable tool that helps stabilise individuals and reduce cravings, which enhances the chances of successful recovery.


Here are the three main medications used:

  • Methadone- It is a long-acting opioid agonist that helps to stabilise individuals by reducing withdrawal symptoms and cravings. Methadone is usually dispensed in specialised clinics.


  • Buprenorphine- This is a partial opioid agonist that also helps in reducing withdrawal symptoms and cravings. It has a lower risk of overdose compared to full opioid agonists like heroin.


  • Naltrexone- This is an opioid antagonist that blocks the effects of opioids. It is used after the detoxification phase, as it can precipitate withdrawal if taken while opioids are still in the system.


These medications are often used in combination with counselling and behavioural therapies to address the psychological and social aspects of addiction.



Integration of behavioural therapies into recovery models


Earlier perspectives might have underestimated the importance of behavioural therapies, with a predominant focus on the physiological aspects of heroin addiction. The evolving understanding recognises the intricate interplay between biology and behaviour in addictions like heroin addiction. Behavioural therapies are now seen as essential components of comprehensive treatment, addressing the psychological, social, and environmental factors contributing to substance use.

Cognitive Behavioural Therapy (CBT), Motivational Enhancement Therapy (MET), Contingency Management and 12-Step Facilitation are all recommended in the overall treatment of OUD.

DSM changes that reflect battles with opioid addiction

The DSM is mainly for categorising mental health disorders, not giving treatment advice. Yet, looking at how opioid-related issues are classified in different DSM editions shows how our understanding of opiate addiction has changed over time.

The table below demonstrates the evolutionary changes in the classification and terminology of opiate addiction across different editions of the DSM.

DSM Edition Year Term Used for Opiate Addiction Notes
DSM-I 1952 No specific term for opiate addiction The DSM-I did not have a specific classification for opiate addiction.
DSM-II 1968 Opiate addiction The DSM-II introduced the term “opiate addiction” without detailed criteria.
DSM-III 1980 Opioid Dependence The DSM-III introduced the term “Opioid Dependence” with specific diagnostic criteria.
DSM-III-R 1987 Opioid Dependence The DSM-III-R maintained the term and criteria for “Opioid Dependence” with minor revisions.
DSM-IV 1994 Opioid Dependence and Opioid Abuse The DSM-IV introduced the distinction between “Opioid Dependence” and “Opioid Abuse” as separate diagnoses.
DSM-IV-TR 2000 Opioid Dependence and Opioid Abuse The DSM-IV-TR (Text Revision) maintained the same classifications and criteria as the DSM-IV.
DSM-5 2013 Opioid Use Disorder The DSM-5 combined “Opioid Dependence” and “Opioid Abuse” into a single category called “Opioid Use Disorder” with severity levels ranging from mild to severe.

Note: All information is taken from the respective DSM manuals.

The way we describe opioid-related issues has changed over time. Initially, there was no specific term in the DSM-I, but later editions introduced terms like Opiate Addiction, Opioid Dependence and Opioid Use Disorder.

In DSM-II, there was a shift from Opiate Addiction to Opioid Dependence, reflecting a broader view that includes both natural opiates and synthetic opioids. DSM-IV further separated Opioid Dependence and Opioid Abuse to classify the severity of substance use disorders.

The DSM-5 took a different approach by combining Opioid Dependence and Opioid Abuse into a single category called Opioid Use Disorder. This change aligns with a trend in the DSM-5 to focus on the severity of the disorder rather than strict categories.

The DSM-5 also introduced severity levels within Opioid Use Disorder, recognizing that substance use disorders exist on a spectrum, showing a more nuanced understanding of the complexity of opiate addiction.

The changes in the DSM related to opioid addiction signify progress in understanding and addressing the issue. However, it may feel slightly bittersweet due to the immense toll on users, families, and communities. Ongoing efforts are vital to finding comprehensive solutions that reduce negative consequences and promote public health and well-being.

Expansion of access to treatment for OUD sufferers

Historically, there may have been stigmatisation surrounding addiction, leading to limited access to treatment services. The opioid epidemics have brought attention to the need for broadening access to care.

Nora Volkow, the Director of the National Institute on Drug Abuse (NIDA), asserts that medications undeniably stand out as the most effective approach for treating OUD, significantly lowering the risk of overdose death by up to three times.

Despite this, she notes that less than half of the patients who could benefit from these medications actually receive them due to societal stigma and structural barriers.

Volkow’s advocacy for Medication-Assisted Treatment (MAT) signifies a progressive shift in tackling OUD, departing from traditional approaches. While the commitment to expanding MAT within healthcare and criminal justice systems is commendable, it highlights the ongoing need for a more inclusive paradigm in OUD treatment.


Emergency departments can no longer ignore addictions

In the US specifically, hospitals are legally obligated to provide effective care for individuals with issues with such as heroin. Despite the current escalating addiction and overdose crises in the US, emergency departments often discharge such patients without recommended care.

Analysis reveals that failure to identify and treat substance use disorders may violate federal laws, prompting legal consequences.

The report recommends three evidence-based practices for emergency departments:

  • Screening and diagnostic assessment


  • Utilising FDA-approved medications for OUD


  • Facilitating referrals to ensure continued treatment and long-term support for managing substance use disorders.


In the past, it may have been common for individuals struggling with substance use disorders to be frequently subjected to punitive measures rather than receiving compassionate and evidence-based care. There may have been less emphasis on addressing the underlying medical and psychological aspects of addiction.


OUD training for healthcare professionals

Earlier views may have downplayed the role of healthcare professionals in addressing addiction, with limited training provided in medical education. The evolving understanding emphasises the importance of healthcare professionals in identifying and treating substance use disorders. Training programmes, like the ones provided by the USA’s CDC, have expanded to equip healthcare providers with the knowledge and skills necessary to address addiction as a chronic medical condition.

Final thoughts

The history of opioid epidemics has prompted important changes in how the medical and psychological field deals with opioid addiction.

The evolution of terms in the DSM, the adoption of Medication-Assisted Treatment and the recognition of behavioural therapies showcase a growing understanding of opioid complexity. Efforts to expand treatment access reveal progress but also highlight ongoing societal challenges.

Emergency departments are now urged to provide evidence-based care, and healthcare professionals receive better training, showing a huge step in the right direction.

Despite these positive steps, the opioid crisis remains an ongoing challenge, emphasising the need for continued efforts to enhance public health and well-being.
Are you struggling with heroin addiction?
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