Despite epidemic levels of overdoses in the United States, by 2020, only twenty percent of Americans suffering from opioid use disorder (OUD) received medication-assisted treatment (MAT), the gold standard of addiction treatment, which uses methadone, buprenorphine, or naltrexone to reduce illicit drug use and curb the symptoms of withdrawal. While MAT is the most effective treatment available for OUD, it’s also the most controversial, the most expensive, and the most difficult to access. And yet, the medications at the center of this treatment—and the private industries that distribute them—generate roughly sixteen billion dollars each year, on par with national sales of coffee and pet food. In Addiction, Inc., historian Emily Dufton explains how this promising avenue of treatment emerged during President Richard Nixon’s war on drugs in 1971 as a radical experiment in public health, when hundreds of federally-funded treatment clinics opened nationwide. Dufton then explores how these nationalized clinics gave way to an immensely profitable private industry that offers poor care at high costs to an insufficient number of people. Read on for a Q&A with Dufton about the book.

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You open the book with a personal story about your friend Dana, whose life was impacted by opioid addiction. How did he inspire this topic?

That’s right. The first sentence of Addiction, Inc. is, “I wrote this book because Dana died.”

In 2016, my friend Dana hanged himself in the woods behind our old middle school after 15 years of steadily escalating opioid use. To me, his death posed a research problem. I wanted to understand what could have kept someone like Dana alive, and what kind of treatment options could have improved his results. When I polled doctors and experts, I was told that Dana should have been placed on “medication-assisted treatment” (MAT), a form of treatment that uses one of three FDA-approved medications to treat opioid addiction as a legitimate disease. Doctors called MAT the “gold standard” of treatment because it lowered the risk of overdose death and drug-related disease, and it decreased the risk of relapse, making it easier for people to engage in recovery.

So I wondered, if MAT was so great, then why didn’t Dana get it? And not just Dana, but a dozen other classmates who died from overdoses and suicides over the years, and the million Americans who overdosed on opioids since 2000? That question drove me to research the history of MAT—where it came from, who developed it, and why. The result is Addiction, Inc.

Some readers will be surprised to learn about the Nixon administration’s role in the history of MAT. What led the Nixon administration to fund hundreds of treatment clinics nationwide?

Three things: rising rates of heroin use and crime in the United States, and the threat of addicted soldiers returning from Vietnam. It was Vietnam that really pushed the president’s hand.

In 1969, when Nixon squeaked into the White House, drugs and crime were endemic in Washington, DC, with over 200 felonies reported each day. In response, Nixon turned the only 68 square miles in the United States that were entirely under federal control into a “national laboratory” in which to test the newest, most advanced crime-reduction techniques. These included more cops on the streets, better streetlights, and faster criminal processing. But as DC’s jails filled, crime and heroin use continued to rise. “Law and order” didn’t work.

Then, in April 1971, two congressmen returned from a tour in Vietnam with terrifying news: 10 to 15 percent of servicemen there were addicted to the pure, cheap, and readily available heroin that was pandered from roadside stalls. The congressmen, and soon a media firestorm, warned these combat-trained “GI Junkies” would cause incomprehensible harm if they returned to America with their addictions intact.

In response, on June 17, 1971, President Nixon declared a “new, all-out offensive” against heroin, “public enemy number one.” But this battle didn’t involve more arrests or police. Instead, Nixon’s new battle would launch a nationalized system of addiction treatment clinics nationwide. Dr. Jerome Jaffe, a psychiatrist from Chicago, was named director of the new executive-level Special Action Office for Drug Abuse Prevention (SAODAP), which was going to use two-thirds of the federal drug budget for “demand reduction” programs like treatment, prevention, and education.

In two years, SAODAP developed the largest treatment infrastructure in American history. By 1973, over 70,000 people were receiving services from hundreds of federally funded clinics nationwide, offering everything from abstinence-based programs like detox centers, counseling, and therapeutic communities, along with daily methadone maintenance. That was the culmination of the “all-out offensive” Nixon launched on June 17, 1971 – a nationalized healthcare system providing services to tens of thousands of heroin users each year.

What was the result?

Well, for a while, it was pretty good! By 1972, overdose deaths were down. Drug-related diseases and emergency room visits were down. Drug crime was down, and drug arrests were down. In fact, crime was down nationwide, the first decrease after a two-decade-long spike. It helped that the French Connection was busted that year as well, so the heroin trade to America was severely disrupted. But within a little over a year, SAODAP’s system was making a real impact on heroin use in the United States. It worked out well for Nixon too. He was reelected in a landslide that November.

Things quickly took a turn, however. Methadone in particular was deeply controversial. Black communities viewed it as a form of “narco-genocide,” psychiatrists feared the White House was using treatment as a “covert agenda,” and private doctors who simply sold the drug were held responsible for the increasing number of methadone overdose deaths. In 1973, methadone clinics were saddled with strict regulations, private sales were outlawed, and the White House turned back to “law and order.” SAODAP dissolved with Watergate and was reborn in 1974 as the National Institute on Drug Abuse (NIDA). In the decades since, NIDA has devolved into a small, fourth-tier research bureau, first in the Department of Health, Education, and Welfare and now in the National Institutes of Health. But it’s nothing like the powerful and radical executive office SAODAP once was.

The story doesn’t end with methadone, however. SAODAP (and then NIDA) was congressionally mandated to pursue research into other treatment drugs. From that research came the development of all the other MAT medications, including naltrexone (known by its brand names Trexan and Vivitrol), buprenorphine (brand name Suboxone), and a drug no longer used today called l-alpha-acetylmethadol, or LAAM.

In other words, the entire field of MAT exists because of Nixon’s 1971 drug war.

How did our system shift so heavily toward the private sector?

In 1981, under the guise of “Reaganomics,” President Ronald Reagan cut federal funding for methadone clinics, packaged the remaining treatment money into “block grants” for the states, and removed any remaining SAODAP employees from NIDA. The federal drug treatment system SAODAP, created a decade prior, was surgically dismantled by the Reagan administration, which turned toward a literally-militarized “war on drugs” in the mid-1980s with the arrival of crack cocaine.

In response, methadone clinics—which provide patients with a daily medication and, if closed, push patients to the black market—were forced to privatize to stay open. Today’s heavily privatized methadone system comes directly from this moment. From a nationalized treatment system in the 1970s, private equity firms now own the majority of clinics in 21 states, with ownership stakes in roughly a third of the country’s 2,000 total clinics. Methadone appeals to private equity groups because of how it operates as a business, not as a treatment program. Clinics have a guaranteed customer base, consistent and recurrent income, and a government-imposed monopoly on the few outlets that are registered and certified. As a private industry, methadone is seen as a sound investment. As a public health initiative, however, our overdose rates speak for themselves.

For the other MAT medications, privatization came after the federal government was instrumental in the drug’s development. With naltrexone, NIDA researchers partnered with DuPont to get the drug approved in 1984 as Trexan, a daily pill. DuPont officials said they never would have developed the drug without the government’s help, since they knew Trexan was never going to be a big money-maker. Similarly, NIDA partnered with a small firm in Virginia to develop a commercial version of LAAM called Orlaam, which died in the 1990s when it couldn’t compete with privatized methadone clinics.

The federal government’s biggest success came after NIDA partnered with Reckitt Benckiser Pharmaceuticals (RBP) to develop buprenorphine as Suboxone in the 1990s. Suboxone was developed as an “orphan drug” because RBP officials believed it would never turn a profit. This was because Suboxone was envisioned—and legalized, after the Drug Abuse Treatment Act of 2000—for treatment outside government-regulated methadone clinics, and few private doctors wanted to treat addiction.

But soon, RBP hired hundreds of laid-off Purdue salespeople, who started selling Suboxone to the same doctors to whom they once sold OxyContin, and by 2012, Suboxone was earning over a billion dollars a year for a private company, RBP. Suboxone’s Shakespearean saga, with its twists, turns, and blatant corporate greed, ultimately resulted in the largest opioid settlement of its time in 2020, which was ignored in the wake of a global pandemic. But Suboxone’s story—of the profiteering that follows the privatization of a publicly-developed addiction treatment—is disheartening. Despite its federal origins, Suboxone is another tale of the pursuit of profit over public health, and it did little to solve the overdose epidemic that spiraled in its wake.

You discuss substance abuse treatment in Switzerland as an alternative to our current system. Briefly, how does treatment there differ from treatment here?

In America, opioid treatment programs today are haunted by decades of politics and profiteering. The three MAT forms available—methadone, buprenorphine, and naltrexone—are siloed into separate medical and legal entities, with little coordination between treatment programs or between treatment and the larger healthcare system. A patient seeking help today can either go to a heavily-regulated methadone clinic, or try to find a physician willing to prescribe buprenorphine or offer naltrexone. Most of these programs will only be available through private, for-profit systems, which historically have refused insurance and charged cash. So it’s odd that all of these programs were born in the 1970s, when America briefly had an organized, nationalized, non-commercial treatment alternative—a system Switzerland still has.

Forty years ago, Switzerland was the European capital of heroin addiction and HIV. By 1986, “Needle Park,” behind Zurich’s main train station, was a massive open-air drug market. But the Swiss quickly tackled the problems of drug use and viral spread with the federal adoption, in 1992, of a “four-pillar approach.” To contain heroin and HIV, law enforcement would work in coordination with treatment, prevention, and harm reduction.

On the ground, this meant low-threshold methadone clinics opened as police cleared away open-air drug markets, and supervised consumption sites contained remaining illicit drug use. Methadone clinics evolved to offer psychiatric, behavioral, and general healthcare, and offered every other medication available, including buprenorphine, long-acting morphine, and heroin-assisted treatment. After a 1996 federal mandate required all Swiss citizens to have healthcare, available from a new state-regulated, non-profit system, clinic services, including social services, were covered by insurance, which made the bulk of treatment, for most patients, free.

In the decades since, the Swiss have further embraced their “four-pillar approach,” and today addiction treatment in Switzerland is organized, coordinated, attractive, and effective. There are fewer than 200 opioid overdoses in Switzerland every year, compared to the over 54,000 opioid overdose deaths in America in 2024. As one Swiss doctor told me, “That’s the key to actually solving the problems of addiction and restoring social order and public health. You can’t fight it or eradicate it or profit off it. You have to integrate it.”

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Emily Dufton is the author of Grass Roots: The Rise and Fall and Rise of Marijuana in America. The recipient of a Whiting Creative Nonfiction Grant, her writing has appeared in the Washington Post, Smithsonian magazine, and other publications. She lives with her husband and children outside Washington, DC.

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