In the United States, the magnitude of opioid use disorder, a high-mortality disease previously called drug addiction, has enabled the rise of a lucrative treatment industry that splits into two branches: abstinence-based and medication-assisted. Emily Dufton is the first historian to seriously document the latter. In doing so, she establishes a timeline starting with methadone for heroin users in the 1960s and continuing into the present era of Suboxone for fentanyl users. Addiction, Inc. offers a close inspection of the six-decade effort by government and industry to develop pharmaceutical solutions to an apparently unsolvable drug problem. Therapy aside, US consumers now spend as much on these medications as they do on pet food, yet the overdose crisis rages on.

Basing her work on primary sources and interviews with more than 100 bureaucrats, scientists, and CEOs, Dufton writes a clear, detailed history of medication-assisted treatment (MAT). The book focuses on the struggle to bring to market a series of synthetic drugs, mostly opioids themselves, that might serve as chemical placeholders or deterrents for widely abused, euphoria-producing painkillers. Contrary to the common perception of him as a strictly law-and-order drug warrior, Richard Nixon himself jump-started MAT with robust federal support for methadone maintenance clinics after the public learned of widespread heroin use by US soldiers in Vietnam. The unlikely drug czar Jerome Jaffe gets biographical treatment in the first part of Addiction, Inc. as he navigated daunting regulatory hurdles, ultimately delivering medically dispensed methadone on a national scale and opening the door to the very idea of pharmaceutical treatment for drug dependence.

Support for maintenance waxed and waned dramatically over the following half-century. Ronald Reagan nearly killed it in favor of abstinence and tough love. But researchers and federal health agencies persisted, developing other synthetics (naltrexone, buprenorphine) to address methadone’s shortcomings and appease its detractors. Frustrating problems emerged. For example, patients on methadone maintenance were required to appear daily at a clinic to receive a dose, so when a different drug, LAAM, delivered the same effects when taken only every third day, researchers expected it to make a remarkable impact on the total number of people who could enter maintenance treatment. However, clinic doctors are resistant to the change in their routine, including the daily cash payments they receive from patients, and habituated patients mistrust the new drug. Instead of revolutionizing maintenance, the promising innovation is abandoned. The failed paradigm shift documented in this chapter would make it a fascinating case study in the history of science and allied disciplines.

Indeed, there is much for the reader to analyze in Addiction, Inc. Most maintenance drugs are adaptations of opioids with built-in ceiling effects to prevent overdose and euphoria. When researchers test naltrexone, an opioid antagonist that instead nullifies the effects of any opioids subsequently taken, patients dislike it and abandon the clinical trials. However, a category of “motivated addict” is carved out as good candidates for naltrexone treatment: affluent white professionals whose illegal drug use threatens their jobs or family if they fail to quit. The racial presumptions on display in this attempt at market segmentation are striking.

But one large point, after all, is that pharmaceutical products must have buyers to survive. Despite the book’s title, Dufton gives much more attention to the bureaucracies than the corporations involved in the partnerships that push MAT forward. But she keeps a steady eye on the profit motivation of drug companies, which often receive sweetheart deals from taxpayers without returning the generosity. Such deals come in many forms: expedited FDA approvals, specially extended patents, use of federal research labs and their staffs, and even the formation of new corporations by well-placed government agents. Many familiar quirks of US political history appear in this story as well: the whipsaw of the four-year presidential administration, the ability of a pointedly timed exposé to ruin officials and tank their expensive programs, the periodic dumping of health care responsibilities onto the states, and most of all the blurring of lines between corporate private interests and government public ones.

Many who have assessed Dufton’s book have been struck by her account of how, in the early 2000s, Suboxone was marketed to doctors by a force of former Purdue Pharma sales reps who had been laid off when the company was first blamed for the Oxycodone overdose crisis. In other words, the very same people who had spread the damnation of dependence now offered the salvation of recovery from a different company (Reckitt, a British conglomerate akin to Procter & Gamble). Moreover, as the drug’s patent was set to expire, allowing generic versions to enter the market at a much lower cost, Reckitt’s executives created false safety data and worked the levers of government in order to extend the monopoly it had enjoyed, extracting unearned additional wealth from patients and taxpayers and squashing broader treatment availability. The tale of this mendacity is the most compelling part of the book in spite of leaving little room for analysis. Some historical outcomes can be explained in one word: greed.