Treatment: History of, in the United States

views updated

Treatment: History of, in the United States

The history of the treatment of alcohol and other drug problems in the United States has not followed a simple path. Various views on what causes addiction have often come into conflict. For example, one widely held belief about addicts is that people exercise free will in choosing to use drugs. A different but very common view is that drug addiction is a disease that overwhelms a person's free will. Since treatment efforts began, experts have been searching for insights into the best methods of intervention. This article provides an overview of the treatment methods used from the nineteenth century to the twenty- first century.

The History of the Treatment of Alcoholism

Mutual Aid. In the nineteenth century, people who drank heavily were called "habitual drunkards." (The term "alcoholic" came into use in the twentieth century.) The effort to help habitual drunkards began with the Washington Total Abstinence Movement, or the Washingtonian Movement, in 1842. This movement began a tradition of mutual aid, the banding together of people in similar circumstances to help one another. Mutual aid developed throughout the 1800s in connection to American Protestantism. The Salvation Army, which arose in the United States in the mid-1870s, is also a mutual aid society, as is Alcoholics Anonymous (AA) and the many other groups inspired by AA. Mutual aid is now more often referred to as "self-help," but this term misses the meaning of people helping each other.

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

Washingtonian societies were dedicated to sobering up hard drinkers, usually (but not always) men. Although some famous teetotalers (people who drink no alcoholic beverages at all) like Abraham Lincoln were members, the societies were open to anyone, including the poor, (sometimes) nonwhites, and women. The societies stressed Christian charity, economic self-improvement, and democratic principles.

The Asylum Movement. Samuel Woodward, a Massachusetts superintendent of an asylum, or a home for the mentally ill, was the father of institutional treatment of habitual drinkers. Woodward argued that drunkards could not be treated successfully on a voluntary basis. What they needed, he said, was to be committed (involuntarily) to a "well-conducted institution," or asylum.

The first such asylum, funded by the State of New York, opened in Binghamton in 1864. Other asylums opened in Kings County, New York (1869), Massachusetts (1893), Iowa (1904), and Minnesota (1908). The asylum movement led to dozens of private institutions that treated well-to-do drunkards and, by the 1890s, drug addicts. But overall, the movement for public treatment was a failure. State legislatures did not support them, partly because of their cost, and partly because physicians never could produce a strictly medical "cure" for addiction. Instead, doctors believed recovery could be achieved through bed rest, a healthy diet, and therapeutic baths (hydrotherapy), and the discipline of useful labor.

By the time of Prohibition in 1920, all public asylums for drunkards had been closed or converted to other use. However, the asylum movement did leave a legacy for the treatment for addictions: It stressed an understanding of addiction as a compulsion , and the belief that doctors and medicine were necessary for successful treatment.

The Mental Hygiene Movement. The mental hygiene movement, which began in 1908, took the approach that addiction was strongly influenced by a person's environment—the addict's family and social influences. The movement also believed that addiction could be the result of a biological defect and could be incurable, although if the condition was addressed early on it could be stopped from progressing. Mental hygienists stressed the importance of family, friends, and occupation in creating a healthy environment for an addict's continuing sobriety. Mental hygiene developed into what is called community mental health.

The emphasis on the addict's environment challenged the strictly biological view of the asylum movement. Mental hygienists believed that only voluntary access to free or inexpensive care would attract patients in the early stages of drinking or drug-taking careers. The Massachusetts Hospital for Dipsomaniacs and Inebriates (1893–1920) is an example of how views were changing at that time. It began as a hospital run on the asylum model but in 1908 was completely reorganized to follow a mental hygiene course. Most of its admissions were legally voluntary; the hospital established a statewide network of outpatient clinics; it worked closely with local charities, probation offices, employers, and the families of patients. Known finally as Norfolk State Hospital, it was a preview of what treatment was to become, beginning in the 1940s.

The mental hygiene movement changed the emphasis of the asylum tradition but did not entirely abandon its practices. For example, Norfolk created on its campus a "farm" for the long-term detention of "incurables." From 1910 to 1925, many local governments across the United States established farms to hold repeated public drunkenness offenders and drug addicts. Some of these persisted until the 1960s, and some have been reopened in recent years to accommodate homeless people with alcohol and drug problems.

Modern Alcoholism Treatment

Alcoholics Anonymous (AA), which grew out of the mental hygiene movement of the 1920s and 1930s, has had an enormous influence on the treatment of alcoholism. AA looks at alcoholism as a disease, and this view has affected public and political attitudes toward heavy drinking and treatment methods. Although experts disagree about its effectiveness, AA has spread throughout the United States and around the world, and many groups such as Narcotics Anonymous follow AA's Twelve Steps .

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

During the early 1960s, some state hospitals, particularly in Minnesota, incorporated recovering alcoholics and the principles of AA into their treatment programs. A treatment was developed called the Minnesota model of short-term inpatient care (usually twenty-eight days). This inpatient treatment was to be followed by AA fellowship. Across the country, local councils on alcoholism began to press states and localities for outpatient clinics, keeping alcoholics out of jail, and treatment resources. However, progress was slow. By 1967 only 130 outpatient clinics and only 100 halfway houses (transitional housing) and recovery homes existed to treat alcoholics. Alcoholics continued to be barred from most hospital emergency rooms.

Several important court decisions in the 1960s supported the view that alcoholism is a disease. In 1970, Congress passed the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act (called the Hughes Act, after Senator Harold Hughes of Iowa, a recovering alcoholic). The goal of this act was to encourage a more humane and decent response to people with alcohol-related problems. President Richard M. Nixon signed the legislation establishing the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This legislation made federal funds available for the first time specifically for alcoholism treatment programs. By 1980, thirty states had passed laws to ensure that public drunkenness would not be treated as a crime. A system of community-based alcoholism treatment services began to emerge.

History of the Treatment of Drug Addiction

During the late 1800s, many people were addicted to morphine as a result of poor medical treatment or attempts at self-treatment. But morphine addiction declined after the turn of the century as physicians and pharmacists changed their practices and new laws began to be applied to the dispensing of medicines. At the same time, a growing number of urban young people began to experiment with drugs, especially smoking opium, morphine, and cocaine. By 1910 the public saw drug addiction as the problem of petty thieves, loose-living actors, gamblers, prostitutes, and other suspicious types, along with racial minorities and undisciplined youths. While habitual drunkards were often portrayed as occasionally bothersome fools, drug addicts were portrayed as dangerous and exotic.

Because of the link between drug addiction and crime, many believed that drug addicts should be confined under strict conditions for long periods. The mental hygienists at Norfolk State Hospital believed addicts could not remain sober and favored imprisoning them. State hospitals saw addicts as threats to hospital routine and order.

As the number of state laws against the sale or possession of opiates and cocaine increased in the 1890s, and as enforcement tightened after 1910, county jails and state prisons faced a major problem. Jailers proposed solving this crisis through two treatment strategies. First was the creation of special institutions for drug addicts, such as the narcotic hospitals that opened at Lexington, Kentucky (1935), and Fort Worth, Texas (1938). These hospitals were more like jails, although they were authorized to admit voluntary patients of "good character" whose applications were approved by the U.S. surgeon general. Before they were closed in the 1970s, the two facilities had admitted more than 60,000 individuals.

The second form of treatment proposed by jailers was to set up clinics to provide drugs to registered addicts. Addicts were to receive a certain dose of morphine (occasionally heroin, and very rarely, smoking opium), which would then be reduced over a short time to whatever dose prevented withdrawal . At this point, it was believed, the drug addict would stop taking drugs.

However, few of the clinics worked this way. Many clinic operators believed that their primary aim was to stop illegal drug selling by supplying addicts with drugs through medical channels. Most clinic operators believed that reducing doses to the point of withdrawal was useless if the addict did not then get institutional treatment. As a result, clinic doctors rarely bothered to reduce doses. Following World War II, the clinics closed. The period from 1923 through 1965 was a time of strict enforcement of increasingly severe laws against drug possession and sales. Drug addiction was a problem assigned to the criminal justice system, with many drug addiction hospitals being run by state prison systems.

Modern Drug Treatment

In 1961 the American Bar Association and the American Medical Association published a joint report favoring outpatient treatment for drug addicts and limited maintenance treatment programs for heroin addicts as alternatives to prison sentences. In 1962 the U.S. Supreme Court struck down a California law that made drug addiction a crime. The emerging view was that drug addicts required medical treatment, not imprisonment.

Methadone. An important reason for this change in attitude was the success of experiments in treating heroin addicts through methadone maintenance. Methadone maintenance treatment centers have become widespread, although the treatment continues to be a source of controversy. Critics argue that it encourages users simply to replace one drug with another. Supporters argue that methadone maintenance allows former heroin addicts to live productive and healthy lives.

Heroin addiction is more common in areas where there is a great deal of poverty. Many experts argue that no form of treatment is effective without job and community development to support recovering addicts and to prevent relapse, or a return to drug use following treatment. They recommend that individual treatment using medications must be combined with strategies to improve general living conditions. Many workers in antipoverty programs supported methadone as a useful treatment, but many others did not. In 1966, when New York City launched a major expansion of treatment for drug addiction, it chose to make drug-free therapeutic communities the centerpieces of its effort.

Throughout the middle to late 1960s, publicly supported programs for drug addiction expanded, offering a variety of treatments: therapeutic communities; methadone maintenance programs; compulsory (court-ordered) treatment involving residential rehabilitation; twelve-step programs; religious programs; and a number of traditional mental-health approaches offering detoxification followed by psychotherapy . Yet the total number of treatment programs in the United States remained small.

Community-Based Treatment. A 1966 federal law encouraged the establishment of community-based treatment programs. This expansion of treatment capacity was important also for its attention to problems related to a variety of drugs. It came at a time of sharp increase in marijuana use among middle-class youth, an epidemic of amphetamine use, growing experimentation with LSD, and media focus on the counterculture, or the youth revolt.

President Nixon took office in 1969, and on June 17, 1971, he declared a "War on Drugs." Nixon created, by executive order, the Special Action Office for Drug Abuse Prevention (SAODAP). The creation of SAODAP marked the federal government's first commitment to make treatment widely available. In fact, SAODAP's goal was to make treatment so available that addicts could not say they committed crimes to get drugs because they could not obtain treatment.

Over the next several years, a variety of community-based programs were initiated and/or expanded, including drug-free outpatient programs, methadone maintenance, and therapeutic communities. SAODAP put less emphasis on hospital-based programs. SAODAP also stressed treatment within the military as an alternative to court martial.

During the first two years after SAODAP was created, treatment greatly expanded. In early 1971 there were thirty-six federally funded treatment programs in the United States. Two years later, there were almost 400. Between 1976 and 1982, however, the level of federal support for treatment was cut almost in half, as presidential administrations turned their attention toward prevention campaigns and pursuing policies designed to limit the importation and trafficking of drugs.

Despite a reduction in federal funds since the 1970s, there has been a selective increase in private funding of drug treatment facilities. Beginning in the 1970s, a few insurance industry leaders began to provide coverage for the treatment of alcohol and drug dependence. In response, private hospitals (both nonprofit and for-profit) expanded their treatment capacities dramatically. Commonly, programs consisted of a brief period of inpatient detoxification followed by several weeks of inpatient rehabilitation. After release from the hospital, treatment continued through participation in AA, Narcotics Anonymous, or Cocaine Anonymous. However, people without insurance either had no access to treatment or had to turn to publicly supported programs.

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

Tobacco Treatment

Today, tobacco use is widely considered to be a problem of drug dependence (the drug being nicotine). For most of the twentieth century, however, it was not treated as such by either the medical or criminal-justice establishment.

Tobacco use was frowned on in the nineteenth century by the same groups who disapproved of drunkenness. As far back as the 1890s, advertisements for medicines claimed to help people break the tobacco habit. In the early twentieth century, a wave of temperance groups that advocated sobriety swept across the country, and more than twenty states passed tobacco prohibition laws, though most were quickly repealed. Public concern with tobacco use declined dramatically from the 1920s through the 1950s. Cigarette smoking became an accepted practice among men and grew steadily among women. This situation changed abruptly with the publication of the 1964 Report of the U.S. Surgeon General that linked cigarette smoking to cancer. Since then, increasing attention has been paid to treatment of the tobacco habit. The treatment approach considered most effective is a combination of medications, such as nicotine chewing gum and skin patches, and some kind of behavioral therapy.