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Efforts at combating the negative health and social consequences of substance abuse and dependence have always existed in the United States. Often swinging between the rival contexts of moralistic and positivistic discourses, these efforts have led to the articulation of the major therapeutic paradigms in the field of substance abuse treatment. The earliest interventions were grass-root interventions focusing on individuals with drinking problems whose goals shifted from moderation to abstinence over time. As the patterns of substance use and abuse quickly diversified along the processes of immigration and urbanization, a wider variety of substances and a more diverse assortment of users became targeted for an even richer array of therapeutic experiments. The gradual involvement of the state in the planning and administration of substance abuse treatment has resulted in the growing use of institutionalization and coercion to trigger and maintain the recovery process. The emerging consensus that substance addiction is a chronic and relapsing brain disease represents a redefinition of an old problem and will determine the direction of the science and art of substance abuse treatment in the years to come.
Mind-altering substances have been a part of the human experience since the beginning of civilization (Katcher 1993; Saah 2005). Many of the psychotropic effects enjoyed by recreational drug users today were sought by ancient civilizations as a means of increasing their chances of survival (Saah 2005). Ancient civilizations also realized, however, that it was possible to enjoy and become addicted to certain substances. Five-thousand-year-old Egyptian records report that individuals suffering from alcohol addiction were often cared for in the private homes of people who provided treatment. Records from ancient Greek and Roman sources recommended that alcoholics receive treatment in “public or private asylums” (White 1998). This research paper will provide an overview of American substance abuse treatment from the 1700s to the present.
The Early Years Of America: 1600 To 1900
Americans have consumed alcohol since colonial times, making alcohol the earliest use of an intoxicant by the settlers. Alcohol was an integral part of culture at the time, but public drunkenness was not tolerated (Levine 1978; Stolberg 2006). The production and consumption of alcohol increased steadily between colonization and the late eighteenth century. By 1810, the number of distilleries in the United States had increased exponentially to a staggering 14,191, with the average person drinking four and a half gallons of alcohol per year (White 1998). The level of alcohol consumption had reached its zenith by 1830, with the average American consuming approximately five to seven gallons of alcohol per year (Stolberg 2006). Alcohol had become easily accessible to, and affordable for, the general population, resulting in deleterious effects on society (especially the family) due to increased alcohol abuse (Katcher 1993; White 1998; Stolberg 2006). Treatment of addiction in the United States, therefore, began with alcohol addiction (Lemanski 2001).
Early Institutional Care For Addiction
In the late eighteenth and early nineteenth centuries, individuals suffering from an addiction to alcohol were grudgingly housed in a variety of locations. Individuals who were considered drunkards were frequently incarcerated in local jails (Rosenberg 1995; White 1998; Rothman 2001), which is especially interesting because alcohol was often served in early American jails (Rothman 2001). Hospitals were an option for medical care but were limited in number during the eighteenth and nineteenth centuries. Both almshouses (places for the poor, sick, or destitute to seek refuge) and asylums for the mentally ill also provided a place for alcoholics to stay but, like jails and hospitals, failed to provide treatment for addiction (Rosenberg 1995).
Benjamin Rush, a prominent physician and activist beginning in the latter half of the eighteenth century, proposed that “sober houses” be used to treat alcohol addiction through medical treatment as well as “religious and moral instruction” (Levine 1978; Baumohl 1990; White 1998). Rush, who initially advocated for moderation rather than abstinence, went on to describe the symptoms and potential social consequences of alcohol abuse in pamphlets that were distributed to the public in 1784 (Levine 1978; Katcher 1993; Lemanski 2001; Stolberg 2006). Early treatments of alcoholism used by Rush ranged from cold baths, vomiting, and aversion therapy to the practices of bleeding, blistering, and sweating the patient (White 1998).
Physicians in the early nineteenth century made significant contributions to the identification of key physical consequences of alcoholism, such as liver, stomach, muscle tissue, and nerve tissue damage. Delirium tremens (or the “D.T.s”) were first described prior to 1819 as “alcoholinduced brain fever,” and then later articulated by Dr. Walter Channing and Dr. John Ware between 1819 and 1831. The two physicians provided the first American documentation of a variety of symptoms of delirium tremens, such as hand tremors, hallucinations, vomiting, and loss of appetite. The term “alcoholism” was also coined in the mid-1800s by Dr. Magnus Huss, a Swedish physician who chronicled the development in global knowledge of alcohol addiction (White 1998).
The discovery of the physical side effects and consequences of chronic alcohol use, as well as the ineffective drive for abstinence during the temperance movement, played a role in the push for the institutional treatment of alcoholism (Baumohl 1990; White 1998). The American Association for the Cure of Inebriation (AACI) provided the first attempt at the professionalization of treatment services, arguing that addiction was a disease that should be treated rather than a vice or criminal offense that should be punished. In 1870, six managers of inebriate homes and inebriate asylums joined together to form the AACI. Inebriate homes were small facilities that provided some treatment for alcohol addiction but functioned primarily as a shelter for alcoholics. Inebriate asylums, on the other hand, were often large private or state-sponsored facilities that focused on the provision of medical treatment for alcohol addiction. Private sanitaria (often referred to as lodges or retreats) were also developed at the end of the nineteenth century to provide addiction treatment services to the wealthy (White 1998).
Types of services provided at the different types of addiction facilities included inpatient treatment, shortor long-term stays for detoxification, and the first attempts at outpatient services. The first attempts at a “continuum of care” were also made during the inebriate asylum movement. A local physician would first refer a patient suffering from alcohol addiction to an institution for the purposes of detoxification. After further evaluation, the patient would be transferred to a facility that provided long-term treatment for addiction. After the completion of long-term treatment, the patient would be returned to the care of their local physician, who would then provide any necessary aftercare (White 1998).
Specific treatment methods within individual institutions varied. The most important feature of early institutional treatment was isolating the inebriate from society so that the inebriate would no longer face the temptation of alcohol. Once isolated, many institutions began the process of detoxification. Detoxification could be done abruptly and without the aid medication (often referred to as “cold turkey”) or gradually with medications prescribed to alleviate the symptoms of withdrawal. Other types of psychotropic substances, such as cannabis, coca, chloral hydrate, and belladonna, were commonly prescribed for detoxification during the nineteenth century. Detoxification was often followed by an attempt to restore the patient to a healthy physical state, through the provision of medical treatment, healthy meals, fluids, vitamins, and exercise. It was also believed that massages, sunlight, and electrotherapy would aid in the recovery process. Music, counseling, aversion therapy, and religious instruction were other methods that were occasionally offered, but were not the norm (White 1998).
Construction of institutions for the treatment of alcohol addiction in the United States expanded to a total of one hundred facilities by 1902. This trend of expansion, however, was short-lived. The majority of the inebriate homes and asylums had either disappeared or been reallocated for correctional or psychiatric purposes by the 1920s. Contributing factors to the demise of the inebriate homes and asylums were lack of funding, technology, and professionalization as well as a waning of the optimistic belief that alcoholism could be cured. Although early attempts at the treatment of alcohol addiction were not successfully sustained, they conceptualized addiction as a disease rather than a personality disorder, revolutionized treatment of addiction, and provided the foundation for the continued development of future methods of substance abuse treatment (White 1998).
The Temperance Movement
The temperance movement played a pivotal role in the evolution of substance abuse treatment by sparking a new way of viewing addiction and recovery. The temperance movement began in 1808 as a response to the social problems resulting from the rapid increase in alcohol abuse among the American population (White 1998; Lemanski 2001). Alcohol abuse was initially thought to be a moral affliction rather than a disease. The original goal of the temperance movement, therefore, was to reduce alcohol consumption. Early attempts at reducing alcohol intake usually consisted of replacing spirits with beer or wine (Hall 2010; Stolberg 2006).
Beginning in 1831, a variety of temperance societies were created throughout the country in an effort to promote a communal recovery process rather than an isolated attempt at sobriety. The Washingtonian Society, founded in 1840, was one of the more well known of these temperance societies. The purpose of the Washingtonian Society was to provide a place for alcoholics to meet, hear temperance lectures, and share their experiences of alcoholism and recovery. Their method of recovery required members to publicly acknowledge their addiction and commit to recovery, share their experiences with other members, and engage in leisure activities without alcohol (White 1998). The Washingtonians also attempted to assist their fellow members in times of need, which is an aspect of the society that made it different from other temperance societies operating at the time. Efforts were made, through charitable donations, to offer legal assistance, shelter, food, and clothing to fellow Washingtonians as needed (Lemanski 2001).
The rapid growth of the Washingtonian Society, however, was met with an equally rapid demise. The Washingtonian Society had failed to establish a cohesive ideology, as well as an organized standard of practices for meetings, necessary to support continued expansion of the movement (Lemanski 2001). Perhaps more importantly, however, pledging abstinence was not a sufficient method of treatment for individuals suffering from alcoholism. By 1840, the goal of the temperance movement had shifted from moderation to abstinence (Katcher 1993). This shift in goals was largely a result of the growing recognition that alcoholism could not be cured through simple will power. Advocates in the temperance movement began to argue that the best way to fight alcoholism was to prevent future generations from drinking alcohol by prohibiting the consumption of alcohol (Lemanski 2001; Stolberg 2006).
The temperance movement continued to flourish until the Civil War began in 1861. Although the temperance movement stalled during the Civil War, the movement regained its momentum as a political endeavor after the war ended (Lemanski 2001; Stolberg 2006). Women’s groups, such as the Women’s Christian Temperance Union, began to push harder not only for temperance but also for prohibition. In 1869, the Prohibition Party was formed in an effort to make the distribution and transportation of alcohol illegal in the United States (Lemanski 2001). This policy initiative came to fruition with the adoption of the Eighteenth Amendment to the Constitution in 1920. As will be seen in the next section, prohibition had a powerful impact on substance use, abuse, and treatment among the American population in the early twentieth century (Katcher 1993; Lemanski 2001; Hall 2010).
Early Drug Treatment
While addiction treatment services focused predominantly on alcohol in the nineteenth century, there was a burgeoning interest in the treatment of other drugs (White 1998; Stolberg 2006). It is important to note that the use of psychotropic drugs was legal in the United States until the enactment of the Harrison Act in 1914. The availability of drugs (especially opiates and cocaine) greatly increased during this time period, resulting in the first drug epidemic. Physicians with experience in treating patients with drug addictions (usually to opiates) began discussing addiction in terms of disease rather than moral failure (White 1998).
More women than men used psychotropic drugs during this time period, most likely because opiates were the popular treatment for “female” maladies such as menstruation and hysteria. Opiate addicts in the nineteenth century were, more often than not, educated white women of a higher socioeconomic status. Due to the stigmatization of substance abusers, especially during the female-driven temperance movement, women often hid their substance use and abuse from their family and friends. When women did seek out treatment, the reported ailment was usually of a physical or psychological nature (White 1998).
Ironically, however, early treatments for physical, psychological, and substance abuse disorders often included the prescription of other drugs (Courtwright 2001). Opiates were often prescribed for physical and psychological maladies, while cocaine was often prescribed for alcohol and opiate addiction. Additionally, cocaine was frequently used as an anesthetic during surgical procedures. Unfortunately, the treatment of narcotics prior to the twentieth century predominantly focused on easing the suffering of withdrawal symptoms during the detoxification process through the prescription of other highly addictive psychoactive substances (e.g., codeine, hypnotics, bromides, and chloral hydrate). Early experimentation with maintenance programs began at this time, but the programs were largely ineffective because the narcotics used to maintain the patient continued to provide a high (unlike agonists that are used today, such as methadone). The cycle of addiction, therefore, was often sustained (White 1998).
The Miracle Cure
During the second half of the nineteenth century, several coinciding circumstances provided the perfect milieu for the sale of “miracle cures” for addiction. Miracle cures were usually in the form of a medication that could be taken for a short period of time for the successful treatment of alcohol (e.g., Mickey Finn Powders, White Star Secret Liquor Cure, and the Hay-Litchfield Antidote), hangovers (e.g., Alka-Nox, Wink, and Sober-Up), tobacco (e.g., Nicotol, Tobacco Redeemer, and Gustafson’s Tobacco Remedy), or other psychotropic substances (e.g., Mrs. Baldwin’s Home Cure for Cocaine, St. Anne’s Morphine Cure, and Weatherby’s Opium Antidote). A variety of tonics and syrups consisting of various mixtures of alcohol, opium, morphine, and cocaine promised to cure any addiction in the privacy of one’s own home at a fraction of the cost of institutional treatment (White 1998).
Miracle cures could be purchased over the counter, through mail order services, and were also provided in treatment facilities (e.g., inebriate houses). Aggressive marketing strategies were used to advertise miracle cures to the public through the use of newspapers, magazines, billboards, and speaking events. Gimmicks, such as the use of the testimonial (e.g., 100,000 satisfied customers), the money-back guarantee, and discreet packaging, became very popular during this time period (White 1998). Some of these miracle cures, such as Leslie Keeley’s Double Chloride of Gold Cure, actually became treatment franchises (Baumohl 1990; White 1998). Doctors and charlatans alike frequently attached their names to the production and promotion of a new, top-secret formula (e.g., Dr. Meeker’s Antidote) that would purportedly revolutionize the treatment of addiction. The sale of miracle cures continued well into the mid-twentieth century (White 1998).
1900 To The 1950s
The goal of prohibition was to make the distribution and transportation of alcohol illegal so that the consumption of alcohol would become impossible. If the consumption of alcohol could be prevented, it was reasoned, then alcohol addiction would cease to be a social problem necessitating treatment (Hall 2010). Unfortunately, alcohol abuse rose while treatment options disappeared. The idea that alcohol was a physical disease necessitating medical treatment was once again replaced with the belief that alcohol was a lapse in moral character that could be cured by prohibiting inebriety. As a result, religious groups such as the Salvation Army continued to provide treatment services to alcoholics, but the institutional treatment of addiction completely disappeared until the late 1940s (White 1998; Lemanski 2001).
The Effect Of Criminalization Of Drugs On Addiction Treatment
Although it is widely believed that the “war on drugs” began with President Nixon in the 1970s, it could be argued that the “war” began with the passage of the Harrison Act in 1914. Prior to the Harrison Act, access to opiates, cocaine, and other drugs was unregulated. This lack of regulation, combined with the over-prescription of both drugs, resulted in high rates of addiction. In 1912, the first morphine maintenance clinics opened in an attempt to treat the many men and women who had become addicted to opiates. Outpatient treatment was provided through the prescription of decreasing amounts of morphine for the purpose of weaning patients off of drugs at a pace that would allow them to avoid withdrawal symptoms (White 1998).
When the Harrison Act was passed, the possession of illicit substances was criminalized. It was at this point in history that the treatment of substance use and abuse shifted from a public health model to a criminal justice model. The passage of the Harrison Act limited the access to opiates and cocaine to physicians, who were then prohibited from prescribing the drugs to addicts for the purposes of detoxification or maintenance because the government believed that too many addicts were remaining on maintenance programs indefinitely rather than being weaned off of drugs (Levine 1978; White 1998; Courtwright 2001). By 1925, all of the morphine maintenance clinics had been closed (White 1998).
Thus, although the Harrison Act was intended to address opiate and cocaine addiction, it made it very difficult for addicts to receive any treatment whatsoever. Shortly after drugs were criminalized, the mandatory detention of substance users and abusers began. Many individuals suffering from addiction were sent to psychiatric hospitals or special “colonies” for mandatory treatment. Jails and federal penitentiaries were also flooded with addicts who had violated the Harrison Act. Between 1915 and 1929, the number of drugrelated incarcerations increased from 63 to 1,889. Overcrowding of correctional facilities led to the creation of two federally funded and managed “narcotics farms,” which served as separate facilities for drug offenders in need of long-term treatment (White 1998).
Drug abuse and dependence treatments during the first half of the twentieth century were often experimental in nature. For example, treatments for alcoholism were often applied to drug users. Other extremely invasive methods were also used, such as insulin-induced comas, electroconvulsive therapy (ETC), aversion therapy, psychosurgery (i.e., lobotomy), and serum therapy (where serum was withdrawn from blisters that were raised on the abdomen of a patient and then reinjected). Psychological approaches for the treatment of alcohol and drug addiction were also developed during the early nineteenth century, with psychoanalytic approaches being the predominate format. Although the prohibition of alcohol was eventually deemed a failed social experiment, the criminalization of other psychoactive substances remains to this day (White 1998; Lemanski 2001).
The Modern Alcoholism Movement
After the enactment of the Twenty-first Amendment to the US Constitution in 1933, prohibition ended and a new phase in the treatment of alcohol addiction began (White 1998; Lemanski 2001). A third paradigm shift in the treatment of addiction occurred between 1933 and 1955. This period is often referred to as the “Modern Alcoholism Movement” (p. 178). During this time, alcoholism was once again reconceptualized as a disease and public health issue rather than a moral weakness. Professionals and members of society alike began to believe that alcoholism could be treated. This new belief in the merits of treatment opened the door for the allocation of funds for new research on addiction to be conducted by professionals in the medical, psychological, and social work fields (White 1998).
The Modern Alcoholism Movement was not, however, a unified process. The activities of a variety of institutions and interest groups, often with very different agendas, worked separately to achieve social change. Three of the most prominent professional groups to exact change during this period were the Research Council on Problems of Alcohol, the Yale Center of Alcohol Studies, and the National Committee for Education on Alcoholism. These three groups collectively succeeded in redefining alcoholism; changing policies and treatment practices relating to addiction; convincing government and private sources to invest money in research, education, and intervention; and initiating alcohol treatment in the workplace. Another interest group, Alcoholics Anonymous, used a grassroots approach to become an especially integral part of the Modern Alcoholism Movement (White 1998; Lemanski 2001).
Treatment options for alcoholics had all but disappeared in the United States by 1930. In 1935, Bill Wilson and Dr. Robert Smith developed a self-help recovery group called Alcoholics Anonymous (A.A.) in an effort to fill this treatment void (Hubbard et al. 2009). A.A. evolved out of a nondenominational group, known as the Oxford Group, who sought to encourage positive societal change through individual spirituality. Although alcoholism was not the primary concern of the Oxford Group, many group members believed that religion could provide a strong foundation for individuals seeking sobriety. A small subgroup of alcoholic members, led by Wilson and Smith, formed within the Oxford Group to provide support to one another during their struggle for sobriety. The nonalcoholic members of the Oxford Group disagreed with this focus on sobriety, which led to the separation of this subgroup in 1937 (White 1998; Lemanski 2001; Alcoholics Anonymous 2012). The group was christened Alcoholics Anonymous in 1939 (White 1998; Alcoholics Anonymous 2012).
While the early years of A.A. consisted of relatively unstructured group meetings, Wilson and Smith soon began to focus on building a financially independent group with a guiding ideological framework. In 1938, Wilson began writing a book (called Alcoholics Anonymous) that outlined how he wanted the program to function and recorded the stories of the recovery of many of the group members. What began as six guiding principles eventually turned into the twelve-step program that A.A. is known for today. The twelve-step program provides an outline for the course of recovery that an alcoholic will follow as a member of A.A. (e.g., the member must admit that they have a problem and that they need help, put their faith in God, make amends, acknowledge that sobriety is a lifelong commitment). In this way, the focus was not on how or why the individual became an alcoholic. The focus has always been on how the individual will achieve sobriety, and the identity reconstruction that must occur for the individual to remain sober (Alcoholics Anonymous 2012).
After the publication of their book in 1939, A.A. gained a great deal of press coverage, which resulted in enormous popularity. Membership quickly grew to 100 members within that first year and then skyrocketed to 8,000 members by the end 1941 (White 1998; Lemanski 2001; Alcoholics Anonymous 2012). A.A. then began to play a pivotal role in the medical treatment of alcoholism. Hospitals had always grudgingly treated (or refused to treat) alcoholics because it was believed that alcoholism was the result of a moral weakness rather than a disease. Alcoholics also tended to be very difficult and frustrating patients, in already overcrowded facilities, who did not pay their bills. Members of A.A. made it their mission to change the perception of alcoholism from an untreatable moral weakness to a disease with the potential for successful treatment, and they succeeded (White 1998).
Through tireless advocacy, A.A. (1) convinced local hospitals that alcoholism could be treated, (2) showed hospitals how to treat alcoholism, (3) suggested that separate wards be established for the sole treatment of alcoholism, (4) suggested that these wards be managed by A.A. members to take the stress off of hospital employees, and (5) promised to pay the bills of any patient that A.A. had sponsored for alcohol treatment. A.A. then began to extend their treatment model to private, psychiatric hospitals, and prisons, thus playing a major role in the return to the disease model of addiction treatment (White 1998).
In 2011, it was estimated that there are 2,057,672 members worldwide (Alcoholics Anonymous 2012). A.A. has evolved into “the most fully developed culture of recovery that has ever existeda culture with its own history, mythology, values, language, rituals, symbols, and literature” (White 1998, p. 162). The founders of A.A. chose to use the personal experiences of group members who have experienced alcoholism to provide support and guidance in the recovery process rather than utilize the services of professionals in addiction treatment. Nevertheless, Alcoholics Anonymous revolutionized addiction treatment in the first half of the twentieth century and has continued to influence social policy well into the twenty-first century (White 1998).
1950s To The Present
The Minnesota Model
The Minnesota Model of addiction treatment began with the establishment of a new method of alcoholism treatment in three Minnesota centers in the late 1940s: Willmar State Hospital, Pioneer House, and Hazelden. Willmar State Hospital functioned as an inebriate hospital beginning in 1912 but was converted into a psychiatric facility as a result of prohibition. Pioneer House opened its doors in 1948 in an effort to offer a different type of treatment option. Using A.A. as a program model, Pioneer House provided residential treatment for men with alcohol addiction for two to four weeks (White 1998). Hazelden Farm, a former retreat for alcoholic men, was then established a year later to offer A.A.-based residential treatment program (Hazelden 2012).
What is known today as the “Minnesota Model” evolved throughout the 1950s. One of the primary tenets of the Minnesota Model that emerged during this period was respect. The Willmar team argued that patients would greatly benefit from a recovery process built on mutual respect rather than degradation, which was a radical idea during this period. The staff at Willmar then defined alcoholism “not as a symptom of underlying emotional problems, but as a primary, progressive disease” (White 1998, p. 203) that should be treated using a multidisciplinary and holistic approach. They also believed that professionalization of addiction treatment was an integral part of this approach. Medical treatment was to be provided by doctors and nurses, counseling was to be provided by psychologists and social workers, and spiritual guidance was to be provided by the clergy. Perhaps more importantly, however, recovered alcoholics were also professionalized through training and the provision of credentials. The Willmar team believed that recovered alcoholics were often the best counselors, but their position as a part of the addiction treatment team needed to be legitimized. The radical idea of professionalizing recovered alcoholics was met with a great deal of resistance but has become routine in current treatment models (White 1998).
The Minnesota Model continued to flourish and solidify during the 1960s at both Willmar and Hazelden, with several core elements emerging during this period (White 1998; Hazelden 2012). A 28-day stay became the standard treatment period, and patients were first prescribed medication to aid in the detoxification process (Lemanski 2001). A counselor, who often times was a recovering alcoholic, was assigned to each patient. Patients and counselors were usually matched according to age and gender in an effort to establish a supportive environment in which the patient would feel comfortable engaging in self-disclosure (White 1998). Individual counseling was supplemented by group counseling (which combined support and confrontation), lectures, and working through the twelve steps of A. A. Patients also received aftercare upon their return to the community (Quinn et al. 2004).
The Minnesota Model was immensely popular and had been adopted by 114 state agencies that provided addiction services by 1971. Presentation of the Minnesota Model at medical conferences took the treatment approach nationwide. Individuals suffering from alcohol addiction, as well as practitioners who wanted to be taught the treatment method, began pouring in from around the country. This innovative approach of treating chemical dependency is still followed today for both alcohol and drug addiction (White 1998; Lemanski 2001; Quinn et al. 2004).
The Resurgence Of Drug Treatment
Treatment models for alcohol addiction and drug addiction evolved in vastly different ways due to the early criminalization of drug use. While treatment options for alcoholics continued to evolve, drug addicts began seeking treatment in psychiatric hospitals after the morphine maintenance clinics closed in the 1920s because there was literally nowhere else to go. Rapid withdrawal, and perhaps some psychiatric treatment, was the only help that drug addicts received in these facilities. A slight resurgence in drug treatment then began to occur in New York City in the 1950s, however, partly as a response to surging rates of adolescent heroin addiction. A few twenty-eight-day residential treatment programs were established inside of hospitals. Upon admission, patients were detoxified and then participated in individual and group therapy. After discharge, outpatient aftercare services were provided. Hospitals were still resistant to treating individuals suffering from drug addiction, so many individuals were committed for twenty-eight-day cold turkey detoxification on Riker’s Island Penitentiary. Correctional detoxification continued until the practice was banned in the early 1960s. Treatments options were bleak, but both drug legislation and methods of treatment were about to be revolutionized in the 1960s (White 1998).
In an effort to fill the treatment void, attempts to use the philosophies of Alcoholics Anonymous began in various locations in the late 1940s and early 1950s. The leaders of A.A. did not want to extend membership to drug addicts, so recovering addicts created their own version of A.A. The first of these meetings, which were called “Addicts Anonymous,” took place in 1947 inside the federal narcotics farm located in Lexington, Kentucky. Addicts Anonymous meetings soon spread to other treatment facilities and hospitals, but when the organization established community-based meetings, the name was changed to “Narcotics Anonymous (N.A.)” to avoid confusion with Alcoholics Anonymous. The two programs are almost identical, with only slight differences in wording. Although N.A. got off to a very shaky start, almost disappearing in the late 1950s, it is now a thriving international organization (White 1998).
The first attempts at community-based support services for recovering addicts returning home after institutional care began in the late 1950s (De Leon 2000). Cities across the country attempted to provide outpatient treatment via social workers to individuals who had recently completed inpatient detoxification. These early attempts were largely unsuccessful, however, because followup appointments were often missed by patients. Continuing care for drug-addicted patients predominantly fell on private physicians, who often treated patients who had overdosed or contracted a sexually transmitted disease. Religious organizations continued to provide outreach services for drug addiction that often included medical and psychological treatment. N.A. also attempted to fill the void in community treatment, but it was not until Synanon, therapeutic communities, and new legislation permitting the use of agonist and antagonist treatment in community facilities that community-based treatment really took off (White 1998).
In mid-1958, a member of Alcoholics Anonymous named Charles Dederich began holding meetings at his home in California during which he experimented with different methods of group recovery for individuals addicted to both alcohol and drugs. These methods of group recovery were often confrontational, bordering on verbally abusive, and were intended to break down the defense mechanisms and excuses of addicts. His experimentation led to the idea for a therapeutic commune where drug addicts could live together during the recovery process. Dederich left A.A. to pursue his new treatment modality (which was essentially a residential treatment program), which he called Synanon (National Institute on Drug Abuse 2008; Janzen 2011). This first phase of development, known as Synanon I, became immensely popular with both the public and practitioners. By 1969, however, Dederich decided to take Synanon I in a new direction. While the goal of Synanon I was to rehabilitate addicts, the goal of Synanon II was to form an alternative lifestyle and to promote societal change. Synanon II evolved into Synanon III in 1974, at which time Synanon was declared a religion (Janzen 2011).
Synanon may have come to a decidedly bizarre end, but it did initiate a movement towards other therapeutic communities. Five hundred therapeutic communities using the early philosophies of Synanon were operating in the United States by 1975 (De Leon 2000). These new therapeutic communities focused on the rehabilitation and sustained recovery by adjusting the lifestyle, relationships, and even the personality of individuals suffering from drug addiction. Aggressive, confrontational, and even humiliating methods of group recovery were often used within a hierarchical system used to motivate patients to work for higher-status positions within the community (De Leon 2000; Inciardi and McElrath 2008; National Institute on Drug Abuse 2008).
Most early therapeutic communities progressed their patients through three phases over a period of 18 months to 3 years. Patients first received isolated treatment within the therapeutic community, were then employed outside of the therapeutic community, and finally engaged in activities at the therapeutic community while living and working on their own (White 1998).
Therapeutic communities continued to evolve into the model that is used today. Residential stays are similar but tend to be shorter, with treatment methods that are not humiliating or as confrontational and aggressive. Today, therapeutic communities are also often linked to the criminal justice system and outpatient centers. Many jails and penitentiaries have therapeutic communities operating within their walls (De Leon 2000; National Institute on Drug Abuse 2008). The continued acceptance of therapeutic communities and other evolving treatment options, however, were contingent upon the wealth of new legislation that was occurring simultaneously throughout the 1960s.
Civil Commitments And Other Legislations
By the late 1950s, individuals who were suffering from drug addiction were viewed as people who were immersed in a destructive lifestyle that they were not willing, or able, to change. It was believed that addiction was a social disease that could be transmitted to other people; therefore, the family and friends of drug-addicted individuals were considered to be in harms way. Civil commitment, the court-ordered institutionalization of a mentally ill individual, provided a solution to these problems at the state level (Inciardi et al. 1996).
Involuntary and voluntary civil commitment to psychiatric institutions was extended to drug addicts in the early 1960s as a way of ensuring that substance abusers were treated rather than incarcerated. It was thought that addicts would be forced into the treatment that they may not be ready to seek for themselves while also preventing the spread of addiction to the community (Maddux 1988; White 1998). Patients were typically committed for 1 to 3 years, during which time they were detoxified and then provided with medical treatment and counseling. After discharge, the patient was returned to their community and received outpatient treatment (White 1998).
Civil commitment was not particularly successful at initiating sustained abstinence. With psychiatric facilities overburdened and patients continuing to relapse, the government became motivated to find different methods of treating patients in noninstitutional settings. The Joint Committee of the American Bar Association and the American Medical Association on Narcotic Drugs released a report in 1961 that recommended treating patients in community clinics. The more radical recommendation of this report, however, was the suggestion that investigations into maintenance programs be resumed. This step towards a disease model of addiction was further supported by several Supreme Court decisions in the early 1960s that prohibited laws that made addiction a crime, framed addiction as a disease deserving treatment rather than punitive action, and cautioned that civil commitment should be used sparingly. This paradigm shift made it possible for researchers claiming that immediate and sustained abstinence is not a realistic outcome for all drug addicts to be taken seriously (White 1998).
Using narcotics to medically maintain individuals suffering from opiate addiction was prohibited in the United States by the Harrison Act of 1914, but research concerning the practice continued to evolve. German researchers began developing a synthetic narcotic (White 1998; Joseph et al. 2000; Inciardi and McElrath 2008), called Dolophine, in the late 1930s. The use of Dolophine was discovered by the United States in the 1940s and was then marketed under several names by Eli Lilly, Inc. beginning in 1947 (White 1998). What is now known in the United States as methadone is an agonist that mimics the effects of other opiates but without the associated high. Methadone, therefore, can be prescribed in decreasing doses to individuals suffering from opiate addiction as way of weaning them off of the opiate without suffering withdrawal symptoms (Inciardi and McElrath 2008; U.S. National Library of Medicine 2009).
Methadone was used successfully for detoxification in a few US Public Health Hospitals in the late 1940s, but the use of narcotics for maintenance was prohibited until the addiction legislation of the 1960s called for research of new treatment methods (Courtwright 2001; Hubbard et al. 2009). In 1963, Dr. Marie Nyswander and Dr. Vincent Dole argued that methadone could be used not only to detoxify but also to maintain heroin addicts while they acclimate to the metabolic changes that occur during the recovery process. They argued that stabilizing the patient while their body underwent drastic physical change could prevent relapse (White 1998; Joseph et al. 2000; Courtwright 2001; Dole and Nyswander 2008).
Early experimentation occurred in intense inpatient settings. Patients received methadone along with counseling, while dosage levels were explored. Experimentation with dosage levels finally paid off in 1964 when Nysander and Dole discovered that one high dosage of methadone prevented intoxication, craving, euphoria, dysphoria, and withdrawal for 24 hours or more (White 1998; Joseph et al. 2000). Patients were able to function normally with very few side effects. Methadone became the wonder drug, and outpatient clinics were constructed all over the country. During the 1970s, federally funded methadone programs were established at record rates as a response to the return of heroin-addicted Vietnam veterans and a surge in urban crime. Today, methadone is provided in outpatient clinics, usually in conjunction with other addiction services (White 1998; Joseph et al. 2000; Courtwright 2001).
Experimentation with other drugs with the potential for maintaining opiate-addicted patients during recovery also occurred during the 1960s. An agonist called LAAM was another viable option discovered for maintaining patients with opiate addiction programs, but methadone remained the more popular of the two options. The effects of another group of medications, known as antagonists, were also explored. Antagonists, (e.g., nalorphine, naltrexone, and naloxone), block rather than mimic the effects of opiates (White 1998; Nutt 2010). These drugs work just as well as agonists (like methadone), but have no street value because they are not effective pain medications, which is a significant advantage. Antagonists are not popular among patients, however, because they do not suppress cravings and they induce withdrawal if taken when a patient has opiates in their system. Researchers have also been experimenting with partial agonists (like buprenorphine) and the combination of agonists with antagonists (like Suboxone®) as a way getting the best of both worlds (Nutt 2010).
Criminal Justice-Mandated Treatment
Prisons have always been major substance abuse treatment facilities, and criminal justice referrals have historically been the largest source of the publicly funded drug treatment admissions in local communities, accounting for 40–50 % of referrals to community-based treatment programs (Farabee et al. 2004). These community referrals and those admissions to prisonor jailbased treatment programs are generally known as coerced treatment. Coercive treatment approaches for drug addiction have been applied consistently throughout the twentieth century, beginning with the morphine maintenance clinics in some communities during the 1920s. The 1930s marked the establishment of the federal narcotics treatment facilities in Fort Worth, Texas, and Lexington, Kentucky. During the 1960s broad-based civil commitment, procedures were implemented in the federal system, as well as in New York and California. The present system, beginning in the 1970s, relies less on formal civil commitment procedures and emphasizes community-based treatment as an alternative to incarceration or as a condition of probation or parole. The inception of the drug court model in 1989 and of the prosecutor-led drug treatment alternative to prison (DTAP) model effectively propel the use of the threat of incarceration as the leverage and the application of graduated sanctions as the calibrator in the recovery process (Sung and Belenko 2006).
Some earlier researchers (Hartjen et al. 1982; Platt et al. 1988) have argued that little benefit can be derived when a drug user is forced into treatment by the criminal justice system because treatment can be effective only if the client is truly motivated and ready to change. The allocation of limited treatment slots to drug abusers who do not really want to be treated is perceived as ethically unjust and clinically unwise. Other researchers, on the other hand, posit that few chronic drug users will enroll and stay in treatment without some external pressure and that legal coercion is as justifiable as any other motivation for treatment entry (Anglin and Maugh 1992; Salmon and Salmon 1983). As a matter of fact, most clients begin their treatment under some type of pressure from their families or employers.
Legal coercion represents a range of options of varying degrees of severity across the various stages of criminal justice processing. It can be used to refer to such actions as a probation officer’s recommendation to enter treatment, a prosecutor’s offer of a choice between treatment and jail, a judge’s requirement that the offender enter treatment as a condition of probation, or a correctional policy of sending inmates involuntarily to a prison treatment program in order to fill the beds. In all these instances, it is hoped that the external motivation (i.e., legal pressure or fear of punishment) may transform into internal motivation (i.e., desire to change and stop using drugs) and therapeutic engagement during the treatment process (Sung et al. 2001).
Decades of evaluative efforts have concluded that coercion in substance abuse treatment is both a therapeutic factor that can be planned and manipulated for recovery purposes (Young 2002; Young and Belenko 2002) and that it is particularly useful when administered as structured, incremental responses to treatment noncompliance (Taxman et al. 1999). Studies after studies have attested the effectiveness of criminal justice-based treatment (National Institute on Drug Abuse [NIDA], 2012). However, and most importantly, the fundamental lesson learned from evaluation research remains this: Coercion can create incentives to enroll and remain in treatment, but coercive tactics by themselves contribute very little to a drug-free lifestyle if they are not supported by evidence-based therapeutic and service components.
Substance abuse treatment in the United States has followed a spectacular trajectory over the past 300 years that was largely influenced by public perception of addiction, as well as social and political movements. The popularity and acceptance of medical models of addiction treatment have ebbed and waned according to strict moral climates, culminating in the interdisciplinary system of treatment that we have today. With the growing consensus that addiction to psychoactive substances is “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences” (NIDA 2010, p. 5), treatment programs currently attempt to use a holistic approach that addresses the many facets of this public health challenge. Research continues to explore the biological, psychological, and sociological causes of addiction in an effort to provide new interventions that can treat addiction more successfully.
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