The use of psychoactive substances has been commonplace in countless cultures for several thousand years. However, substance abuse did not start to be noticed by scientists until the 17th century. From the mid-18th century to the present day, scientists and other medical professionals have worked to understand the complexities of addiction and how it can be effectively treated. The history of addiction treatment is filled with interesting trajectories and shifting schools of thought. This article explores the complex history of substance abuse treatment and the scientific knowledge that helped shape our current understanding of the disease of addiction.
Mid 18th Through 19th Century
While addiction rehab may be thought of as a recent phenomenon, you may be surprised to learn the roots of rehab initially took shape during a period roughly beginning in the mid-18th century. Starting during this time period, alcohol mutual aid societies were created to help address the issue of alcoholism in the community. These societies were originally started by various Native American tribes and used Native medicines and cultural practices.
These societies spread throughout America in the 1830’s coinciding with the temperance movement the was building in the country. Organizations such as the Sons of Temperance, the Independent Order of Good Samaritans and the Ribbon Reform Club centered on mutual self-help and economic help. These reform societies gave rise to the creation of inebriate homes and asylums.
Examples of these facilities include the Lodging Homes for the Fallen. Founded in the 1850’s, these facilities provided short-term stays focusing on non-medical detox. Other examples include New York Inebriate Asylum founded in 1864 and the Keeley Institute in 1870. While a step in the right direction, these facilities were closed by the 1890’s in favor of placing alcoholics and addicts in drunk tanks and hospital wards.
1825 – 1850
Rev. Lyman Beecher’s Six Sermons on Intemperance describes those “addicted to sin” of intemperance, notes presence of “insatiable desire to drink,” and describes warning signs of addiction to distilled spirits.
Dr. Samuel Woodward calls for creation of inebriate asylums.
The Washingtonian Society, organized by and for “hard cases,” will grow to more than 600,000 members before its precipitous decline in the mid 1840s. Many local Washingtonian groups are replaced by a new social institution — the Fraternal Temperance Society, some of which are organized exclusively for “reforming” men.
Frederick Douglass signs a pledge of abstinence and becomes involved in promoting temperance among African American people. His call for abstinence as a foundation of the drive to abolish slavery and prepare Black people for full citizenship anticipated modern Afrocentric models of addiction recovery.
The Swedish physician Magnus Huss describes a disease resulting from chronic alcohol consumption and christens it Alcoholismus chronicus. This marks the introduction of the term alcoholism.
A growing network of inebriate asylums will treat alcoholism and addiction to a growing list of other drugs: opium, morphine, cocaine, chloral, ether, and chloroform.
New alcoholic mutual aid societies – the Ribbon Reform Clubs – spread throughout the U.S. They are named for their members’ practice of wearing a colored ribbon on their clothing so that they could recognize one another and convey a message of hope about recovery to the larger community.
Jerry McAuley opens the Water Street Mission in New York City, marking the beginning of the urban mission movement. This movement, spread across America by the Salvation Army, caters its message and services to the “Skid Row.” The urban missions will birth such alcoholics mutual aid societies as the United Order of Ex-Boozers. The missions are linked to religiously-oriented, rural inebriate colonies.
Dr. Leslie Keeley announces that “Drunkenness is a disease and I can cure it.” He opens more than 120 Keeley Institutes across the U.S., marking the beginning of franchised, private, for-profit addiction treatment institutes/sanatoria in America.
Cocaine is recommended by Sigmund Freud and a number of American physicians in the treatment of alcoholism and morphine addiction.
Bottled home cures for the alcohol and drug habits abound; most will be later exposed to contain alcohol, opium, morphine, cocaine, and cannabis.
As inebriate homes and asylums close, alcoholics are relegated to city “drunk tanks,” “cells” in “foul wards” of public hospitals, and the backward of aging “insane asylums.”
The Charles B. Towns Hospital for Drug and Alcoholic Addictions in New York City marks the beginning of a new type of private “drying out” hospital for affluent alcoholics and addicts.
Early 20th Century
At the dawn of the 20th century, the effort to provide help to those struggling with addiction moved back into specialized facilities. However, the methods of recovery were a grab bag. Charles B. Towne Hospital opened in 1901 and catered to the well-to-do and used what is known as the belladonna elixir to treat addiction. Other facilities offered a combination of spiritual and psychological interventions. Interestingly, narcotic farms open nationwide to provide free care to addicts and alcoholics. However, these farms were seen as prisons, and addicts and alcoholics were the subject of endless research.
This time period was notable in the fact that Alcoholics Anonymous (AA) was formed. Founded in 1935, AA branched off from another organization called the Oxford Group who used Christian values and principles to combat addiction and other problematic behaviors. The formation of AA started the 12-step group movement which is still strong throughout the world. The formation of AA also gave birth to a treatment philosophy called The Minnesota Model. This model focused on abstinence and behavioral change using AA as a template.
1935 – 1950
The first federal “narcotics farm” (U.S. Public Health Prison Hospital) opens. This marks the beginning of federal involvement in addiction research and treatment.
The meeting of Bill W. and Dr. Bob S. (and Dr. Bob’s last drink) mark the beginning of Alcoholics Anonymous (AA).
Recovered alcoholics in AA are recruited at Remington Arms, DuPont, Kaiser Shipyards, and North American Aviation to work in the first modern industrial alcoholism programs — forerunners of today’s employee assistance programs (EAPS).
A Saturday Evening Post article on AA sparks a period of dramatic growth and geographical dispersion of AA.
Marty Mann founds the National Committee for Education on Alcoholism (today the National Council on Alcoholism and Drug Dependence) around the following propositions:
1. Alcoholism is a disease.
2. The alcoholic, therefore, is a sick person.
3. The alcoholic can be helped.
4. The alcoholic is worth helping.
5. Alcoholism is our No. 4 public health problem, and our public responsibility.
Mann calls for a five-prong approach to be achieved by local NCEA affiliates:
1. Launching local public education campaigns on alcoholism.
2. Encouraging hospitals to admit alcoholics for acute detoxification.
3. Establishing local alcohol information centers.
4. Establishing local clinics for the diagnosis and treatment of alcoholism.
5. Establishing “rest centers” for the long-term care of alcoholics.
A new body of alcoholism-themed literature is published: The Lost Weekend (1944), September Remembers (1945), Breakdown (1946), Devil by the Tail (1947), If a Man be Mad (1947), and Under the Volcano (1947).
Disulfiram (Antabuse) introduced as an adjunct in the treatment of alcoholism in the U.S. Other drugs used in the treatment of alcoholism during this period include barbiturates, amphetamines (Benzedrine), and LSD.
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Mid to Late 20th Century
As AA and other 12-step groups continue to grow, the American Medical Association (AMA) creates the first definition of alcoholism in 1952. This definition states that alcoholism is a progressive and chronic disease with environmental, genetic and psychosocial components. This definition is further expanded in 1960 by E.E. Jelinek with the Stages of Alcoholism. The 1950’s also saw the first halfway houses established to help those struggling with addiction get help to recover.
While 12-Step programs flourished throughout the second half of the 20th century, other support groups began to emerge that eschewed 12-step approaches. Examples include SMART Recovery, LifeRing, Women for Sobriety and the Secular Organizations for Sobriety (SOS). Drugs such as Narcan (first approved in 1971) and Naltrexone (1994) were developed. Most importantly, drug addiction was classified as a disease in 1987 by the American Medical Association.
1950 – 1960
The National Institute of Mental Health establishes a special division on alcoholism.
AA membership surpasses 90,000 as America (and Hollywood) becomes interested in the subject of alcoholism. Cinema portrayal of alcoholism includes such noted films as Lost Weekend, Days of Wine and Roses, and Come Back, Little Sheba.
The American Medical Association stops short of declaring alcoholism a disease but does recognize alcoholics as legitimate patients: “Hospitals should be urged to consider the admission of such patients with a diagnosis of alcoholism based upon the condition of the individual patient, rather than a general objection to all such patients.”
The Veteran’s Health Administration begins developing alcoholism treatment units within its national network of VA hospitals.
American Hospital Association passes a resolution to help prevent discrimination against alcoholics. Fordham University School of Social Services offers the first full university course on alcoholism for credit.
The first ex-addict-directed therapeutic community – Synanon — is founded by Charles Dederich. It will be widely replicated in the 1960s and 1970s.
1960 – 1970
American Public Health Association adopts an official statement on alcoholism, identifying it as a treatable illness.
Provision for local alcoholism and addiction counseling are included in federal legislation funding the development of local comprehensive community mental health centers, anti-poverty programs, and criminal justice diversion programs. Such federal funding increases throughout the 1960s.
Dr. Vincent Dole, an endocrinologist, and Dr. Marie Nyswander, a psychiatrist specializing in addiction, introduce methadone blockade therapy in the treatment of narcotic addiction.
The insurance industry begins to reimburse the treatment of alcoholism on par with the treatment of other illnesses. This leads to a dramatic expansion in private and hospital-based inpatient treatment programs. (1964 – 1975)
The Narcotic Addict Rehabilitation Act (NARA) marks a milestone of increased federal involvement in supporting the development of local addiction treatment services.
The American Medical Association passes resolution identifying alcoholism as a “complex” disease and a “disease that merits the serious concern of all members of the health professions.”
Special alcoholism counseling/treatment initiatives begin within all major branches of the U.S. Armed Forces.
Federal Advisory Committee on Traffic Safety acknowledges substantial role alcohol plays in car crashes. Federal agencies in the early 1970s, through the Alcohol Safety Action Program, will promote new impaired driving laws and the rise of remedial education and assessment/referral/treatment services for those arrested for alcohol-impaired driving.
The early 1970s
American Journal of Psychiatry and the Annals of Internal Medicine published the “Criteria for the Diagnosis of Alcoholism.”
The National States Conference of Commissioners on Uniform States Laws adopts the Uniform Alcoholism and Intoxication Act. This leads to the progressive decriminalization of public intoxication and the emergence of social setting detoxification centers across the United States.
The Joint Commission on Accreditation of Hospitals develops accreditation standards for alcoholism treatment programs.
The Food and Drug Administration approves the use of methadone for treating heroin addiction.
U.S. investigators first describe fetal alcohol syndrome (FAS), a pattern of birth defects observed in children born to alcoholic mothers.
Vernon Johnson’s book, I’ll Quit Tomorrow, introduces intervention technologies that will be widely used to reach alcoholics and addicts before they “hit bottom.”
The first of a series of studies on credentialing of counselors working in alcohol and drug treatment programs marks the beginning of a sustained process of certification and licensure of addiction counselors.
Arguments rage over whether alcoholism and “drug abuse” treatment (which have been separate fields for most of the 20th century) should be administratively and clinically merged. Such integration will become widespread at the state and local (but not the national) levels during the 1980s.
The Federal White Paper on Drug Abuse recommends expanded federal support for addiction treatment.
NCA conducts Operation Understanding, a news conference in Washington, DC where 52 prominent individuals, including Astronaut Buzz Aldrin, publicly acknowledge their recovery from alcoholism.
First Lady Betty Ford speaks to the nation about entering recovery from addiction to alcohol and other drugs.
The early 1980s
Mothers Against Drunk Driving, a powerful grassroots advocacy group, is formed.
The U.S. Postal Service issues a first-class stamp imprinted with “Alcoholism. You can beat it!”
Former First Lady Betty Ford lends her name to a treatment center for alcoholism and other drug addictions.
Cocaine Anonymous is founded.
Nancy Reagan’s “Just Say No” anti-drug campaign is launched within a broader “zero tolerance” campaign that will reduce federal support for treatment and mark the beginning of the dramatic rise in the number of drug users incarcerated.
The National Minimum Drinking Age Act requires all states to make a purchase or public possession of alcoholic beverages illegal for anyone under the age of 21 or lose federal funding for highways. This reflects a growing concern about the lowered age of alcohol use.
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1985 – 1990
Time magazine heralds the “new temperance” movement.
The first appearance of crack cocaine focuses on enormous public attention on the illegal drug problem. Concerns about cocaine-exposed infants lead to expansion of treatment resources for women and specialized programs to treat women involved in the child protection system.
Addiction treatment becomes increasingly concerned about “special populations” and launches specialized treatment tracks for women, adolescents, the elderly, gays and lesbians, and the “dually diagnosed.” As the challenges of treating new patterns of cocaine addiction grow, relapse tracks also become a common treatment.
Anti-Drug Abuse Act authorizes $4 billion to fight drugs, primarily through law enforcement.
President Reagan formally announces a renewed “War on Drugs”; the shift away from treatment toward punishment and incarceration intensifies.
American Medical Association calls all drug dependencies diseases whose treatment is a legitimate part of medical practice.
The U.S. Supreme Court declines to overturn Veteran’s Administration regulation — later changed by an act of Congress — that classifies alcoholism as “willful misconduct.”
The publication of Stanton Peele’s Diseasing of America: Addiction Treatment Out of Control marks the full emergence of a movement whose primary mission is opposition to Twelve Step programs and Twelve Step-oriented addiction treatment.
The first specialized “drug court” is started by Miami. It will spur a national movement to link addicted, non-violent offenders to treatment as an alternative to incarceration.
1989 – 1994
Following an erosion of addiction treatment reimbursement benefits by insurance carriers, an aggressive system of managed care all but eliminates the 28-day inpatient treatment program in hospitals and private, free-standing centers. The downsizing and closure of hospital-based treatment units sparks a trend toward the integration of many psychiatric and addiction treatment units and a renewed community trend of incorporating addiction treatment services under the umbrella of mental health or “behavioral health” services. Most inpatient treatment programs shift their emphasis toward outpatient and intensive outpatient services. The loss of residential services adds fuel to a growing recovery home movement.
The early 1990s
NCA changes its name to National Council on Alcoholism and Drug Dependence –marking a significant milestone in the integration of the alcoholism and drug abuse
The American Society of Addiction Medicine publishes its ASAM Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders. The ASAM criteria shift treatment toward a “levels of care” system rather than a single modality indiscriminately applied to all those entering treatment.
The Center for Substance Abuse Treatment is created to expand the availability and quality of addiction treatment.
The Americans with Disabilities acts extends job protection (except in safety-sensitive positions) to recovering addicts in the private sector.
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The U.S. Supreme Court upholds the right of public schools to tests athletes for drug use.
The FDA approves prescription use of naltrexone in the treatment of alcoholism. This marks the emergence of a new generation of pharmacological adjuncts in the treatment of alcoholism and other addictions.
The 21st Century
At the dawn of the 21st century, the use of medications and medication-assisted treatment (MAT) becomes more accepted as a viable and critical treatment option. Medications such as buprenorphine and Suboxone become cornerstone medications for MAT programs. These medications slowly replace methadone as the medication of choice since methadone itself poses a significant risk for addiction.
The early part of the 21st century saw increased legislation to help addicts find help. The Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 and required insurance companies and group health plans to provide similar benefits for mental health and/or substance use treatment seen in other forms of healthcare. Two years later, the Affordable Healthcare Act (ACA) was passed. The ACA ensured that insurance plans offered by state exchanges included substance abuse treatment.
The field of addiction treatment will continue to grow and evolve. With this evolution, new treatments and ways to view addiction and recovery will grow and help more addicts find recovery.