charged with enforcing the law. Physicians who continued to prescribe were indicted and prosecuted. Because of withdrawal of treatment by physicians, various local governments and communities established formal morphine clinics for treating opiate addiction. These clinics were eventually closed when the AMA, in 1920, stated that there was unanimity that prescribing opiates to addicts for self-administration (ambulatory treatment) was not an acceptable medical practice. For the next 50 years, opiate addiction was basically managed in this country by the criminal justice system and the two Federal Public Health Hospitals in Lexington, Kentucky, and Fort Worth, Texas. The relapse rate for opiate use from this approach was close to 100 percent. During the 1960s opiate use reached epidemic proportions in the United States, spawning significant increases in crime and in deaths from opiate overdose. The increasing number of younger people entering an addiction lifestyle indicated that a major societal problem was emerging. This stimulated a search for innovative and more effective methods to treat the growing number of individuals dependent upon opiates. This search resulted in the emergence of drug-free therapeutic communities and the use of the opiate agonist, methadone, to maintain those with opiate dependence. Furthermore, a multimodality treatment strategy was designed to meet the needs of the individual addict patient. These three approaches remain the main treatment strategies being used to treat opiate dependence in the United States today.

Opiate dependence has long been associated with increased criminal activity. For example, in 1993 more than one-quarter of the inmates in State and Federal prisons were incarcerated for drug offenses (234,600), and prisoners serving drug sentences were the largest single group (60 percent) in Federal prisons.

In the past 10 years, there has been a dramatic increase in the prevalence of human immunodeficiency virus (HIV), hepatitis B and C viruses, and tuberculosis among intravenous opiate users. From 1991 to 1995, in major metropolitan areas, the annual number of opiate related emergency room visits has increased from 36,000 to 76,000, and the annual number of opiate-related deaths has increased from 2,300 to 4,000. This associated morbidity and mortality further underscore the human, economic, and societal costs of opiate dependence.

During the last two decades, evidence has accumulated on the neurobiology of opiate dependence. Whatever conditions that may lead to opiate exposure, opiate dependence is a brain-related disorder, with the requisite characteristics of a medical illness. Thus, opiate dependence as a medical illness will have varying causative mechanisms. There is a need to identify discrete subgroups of opiate-dependent people and the most relevant and effective treatments for each subgroup. The safety and efficacy of narcotic