The consumption of alcohol, opioids, cannabis and cocaine have roots in ancient history. The Bible references Noah’s drinking habits and intoxication, and the use of opium in Syria in the 7th century B.C. is well-documented in ancient medical texts. Ancient Incas living in the Andes three thousand years before Christ chewed coca leaves to counter the physical effects of thin mountain air, and the Chinese Emperor Shen Nung wrote about cannabis in 2727 B.C.
Addiction has a long, sordid history in the world and in our country. Tracing the history of addiction and treatment in America, it’s interesting to note the changing attitudes toward what is now considered to be a medical disease and the evolution of its treatment.
Alcohol: The Devil’s Elixir
For much of human history, drinking alcohol has been an acceptable way to pass the time. Intoxication, on the other hand, has always been demonized. Ancient Egyptians cautioned against excessive drinking, Plato and Aristotle were vocally critical of intoxication, and Hindu Ayurvedic writings warn of the dire consequences of drunkenness. Catholic and Protestant leaders approved of drinking in moderation but considered intoxication a sin.
According to the Baldwin Institute, in the 1800s, drunkenness was considered an indication that an individual was capable of engaging in criminal or violent behaviors, and it was therefore regarded as deviant and undesirable behavior. Family and social networks exerted a strong influence against over-imbibing.1
During the Industrial Age, family and social ties were weakened, and in 1849, the term “alcoholism” was coined as more and more people developed an addiction to alcohol. In 1919, the iron-clad influence of anti-alcohol organizations like the Anti-Saloon League and the Woman’s Christian Temperance Union led to the ratification of the 18th Amendment banning the manufacture and sale of alcoholic beverages.
During the 13 years that Prohibition was in effect, it became extremely difficult to find help overcoming an addiction to alcohol. This spurred the formation of Alcoholics Anonymous in 1935.
While Prohibition did curb drinking behaviors and reduced diagnoses of cirrhosis of the liver by two-thirds, the end of Prohibition led to a dramatic increase in alcoholism. People who before Prohibition wouldn’t have drank to excess or even consumed alcohol in public now felt free to do both. According to an article published in the Journal of Public Health, the stigma previously associated with drinking and drunkenness had been all but erased, thanks to disenfranchised young people who shaped new attitudes toward drinking through popular culture in newspapers, magazines, books and film.2
Today, alcohol is the most commonly used addictive substance in the U.S., according to the National Council on Alcoholism and Drug Dependence, which points out that 17.6 million people suffer from an alcohol use disorder.3 Several million more engage in binge drinking patterns that could lead to addiction and dependence down the road.
Opioids: From Opium to Heroin and Prescription Painkillers
Opioids were introduced to the New World in 1620, when physician Sam fuller brought with him on the Mayflower the drug laudanum, a solution of opium and alcohol, which was later used to treat pain on the battlefields of the Revolutionary War.
In the mid-1800s, opium was a key ingredient in a large number of over-the-counter remedies, including myriad tonics and tinctures that treated “female problems.” As a result, middle- and upper-class women were the demographic most affected by opioid addiction.
Chinese laborers who came to America to work on the railroads in the mid-1800s brought with them the custom of smoking opium, and the resulting opium dens that cropped up across the nation led to widespread addiction among men.
During the Civil War, injectable morphine used on the battlefields led to the first wave of morphine addiction, and when heroin was synthesized in 1895, it was marketed as a viable solution to treating this addiction. As a result, heroin addiction began to grow nationwide.
In the early 20th century, the Harrison Tax Act, which levied a tax on anyone importing, manufacturing, selling or distributing opioids, criminalized treating opioid addiction with opioid medication. Today this practice is a widely used and highly successful research-based approach to treating heroin and prescription painkiller addiction.
Between 1919 and 1924, 44 communities established morphine maintenance clinics, run by police departments or public health departments. By 1935, 25,000 physicians had been indicted for violating the Harrison Tax Act, and all of the maintenance clinics were eventually closed under the threat of indictment. This left all but the wealthiest addicted individuals with no treatment options for opioid addiction.
Heroin was a popular drug in the Harlem jazz scene of the 1930s and 1940s and in the beatnik scene of the 1950s, leaving behind scores of addicted individuals. During the Vietnam War, deployed soldiers who were too young to legally drink turned to heroin, which was cheap and easy to find in Southeast Asia. A government fact-finding mission in 1971 found that 15 percent of soldiers fighting in the war were addicted to heroin.
After Vietnam, heroin addiction moved to the inner city, primarily affecting minority males. When pharmaceutical companies began a successful, aggressive campaign in the 1970s to promote the use of prescription opioid painkillers to treat pain, physicians began widely prescribing these medications, leading to a wave of addiction among the white, middle-class demographic. By 2013, over 207 million prescriptions for opioid painkillers were being written each year, a dramatic increase from 76 million prescriptions written in 1991, according to the National Institute on Drug Abuse.4
In response to the growing problem of opioid painkiller addiction and a fourfold increase of accidental opioid overdose deaths between 1999 and 2010, a number of measures were undertaken by the federal government in an attempt to reduce opiate painkiller abuse. These included reformulating opioid medications to make them more difficult to abuse.
In recent years, this has led to difficulty finding opioid painkillers on the street and inflation in their prices. As a result, many people who are addicted to painkillers have turned to heroin, which is easier to find and less expensive than pills.
Today, 2.1 million people are addicted to opioid pain relievers and 467,000 are addicted to heroin. Opioid addiction is considered an epidemic by the government, which is currently working to reduce the stigma attached to addiction and improve access to treatment.
Cocaine: From Celebrated Substance to Serious Problem
German chemist Albert Niemann isolated cocaine from coca leaves in 1859 and wrote that the drug “promotes the flow of saliva and leaves a peculiar numbness followed by a sense of cold when applied to the tongue.”
Cocaine rapidly found fame as a miracle drug, finding its way into over-the-counter cures for a wide range of ailments. In 1886, John Pemberton created Coca-Cola, which was laced with cocaine and touted as a “brain tonic and intellectual beverage.” Cocaine fueled Robert Louis Stevenson as he wrote The Strange Case of Dr. Jekyll and Mr. Hyde in a mere six days in 1886. Actress Sarah Bernhardt, inventor Thomas Edison and President William McKinley wrote testimonials of praise for the drug. Sigmund Freud was one of the most vocal supporters of cocaine as a cure-all, calling his famous paper Uber Coca “a song of praise to this magical substance.”
But the nation’s love affair with cocaine ended as quickly as it began as the drug led to scores of deaths and incidents of psychosis. By 1902, there were an estimated 200,000 people addicted to cocaine, and in 1903, it was removed from Coca-Cola under pressure from the public. In 1914, the Harrison Tax Act outlawed cocaine in the U.S., and its use declined in the following five decades.
In the1970s, a cocaine revival brought the drug back into fashion. During the 1970s and 1980s, cocaine was an integral part of popular culture. David Bowie, Drew Barrymore, Stephen King, Ozzy Osbourne and Robin Williams were among the numerous public figures who developed a cocaine addiction, and using cocaine was considered a pinnacle of a glamorous lifestyle.
In 1982, cocaine use peaked at 10.4 million reported users. By 1998, the number of cocaine users had decreased to 3.8 million. Today, according to the National Institute on Drug Abuse, 913,000 Americans are addicted to cocaine.5
Marijuana: Changing Attitudes
Between the early 17th century and the end of the Civil War, cannabis was widely grown for hemp, the fibers that were used to make products like fabric, paper and ropes. After the Civil War, other materials replaced hemp, but marijuana became a popular ingredient in a number of over-the-counter medicinal products.
After the Mexican Revolution, immigrants arriving in the U.S. introduced Americans to marijuana for recreational use. But during the Great Depression, anti-immigrant sentiments led to escalating concern about marijuana use. The drug was unfairly linked to violence and crime, and by 1931, 29 states had outlawed it.
In 1936, the famous propaganda film Reefer Madness struck fear in the hearts of Americans with its over-the-top and largely false depictions of the horrors associated with marijuana use. An ensuing national campaign against the drug led to the Marijuana Tax Act of 1937, which criminalized marijuana. Later, in the early 1950s, several laws resulted in a mandatory sentence of two to 10 years in prison for first-offense marijuana possession.
The changing cultural and political climate of the 1960s led to more lenient attitudes about marijuana, and its use became widespread among the white upper-middle-class. By 1972, 11 states had decriminalized marijuana, and most other states reduced their penalties for possession, although, according to Pew Research Foundation, only 12 percent of the U.S. population supported legalizing it.6
In 1976, however, conservative parents’ groups gained popularity and power, leading to the War on Drugs in the 1980s. Reagan signed the Comprehensive Crime Control Act in 1984 and the Anti-Drug Abuse Act in 1986. Together, these new laws raised federal penalties for possessing or dealing marijuana. Under the new rules, possessing 100 marijuana plants was worth the same penalty as possessing 100 grams of heroin.
The “three strikes” amendment to the Anti-Drug Abuse Act resulted in life sentences for third-time drug offenders, including marijuana offenses, and the death penalty for kingpins. Many experts point to these strict laws as a cause of the prison overcrowding problem that plagues all 50 states today.
Today, marijuana is the second most commonly used drug after alcohol. According to Gallup, in 1969, only four percent of American adults said they had tried marijuana.7 In 1973, 12 percent had tried it, and by 1977, that number had doubled. Today, 38 percent of American adults say they have tried marijuana, although marijuana use among young adults ages 18 to 29 has declined since it reached its peak of 56 percent of that age group in 1977. In 2013, seven percent of adults who admitted to trying marijuana reported using it regularly.
Sixteen states have recently decriminalized marijuana, and 26 states allow marijuana to be sold and consumed for medical purposes. Americans’ support for legalization has steadily increased over the past decade, and currently, four states and the District of Columbia have legalized marijuana for recreational use.
According to the Substance Abuse and Mental Health Services Administration, marijuana accounted for 356,040 admissions to treatment in 2009. That number decreased to 281,991 in 2013.8
Early Treatments for Addiction
Treatments for addiction in the 19th and early-to-mid 20th century bordered on the barbaric.
Leslie Keeley, a Civil War surgeon, believed that treatment, not prison, reforms alcoholics. In 1879, he founded the Keeley Institute, a medical institution that treated addiction to alcohol, tobacco and narcotics as a disease.
In addition to promoting abstinence through adequate sleep, healthy meals and plenty of water, Keeley developed a cure containing a secret formula that was injected four times a day. All he would reveal of the cure is that it contained “double chloride of gold,” but scholars believe this remedy likely contained alcohol, atropine, strychnine, and apomorphine, according to North Dakota State University.9 According to Keeley’s business partner, “The only patient who ever received Keeley medicine that actually had gold in it almost died.” By the late 1800s, over 200 Keeley Institute franchises were in operation, with a success rate of about 50 percent.
In the late 1800s, morphine was also widely used as a cure for alcoholism. One Dr. J.R. Black suggested that since alcoholism was incurable, doctors should transfer the dependence on alcohol to a dependence on morphine, which he said was less dangerous and addiction to it was less likely to be passed down through the generations. Morphine addiction was also, he said, less likely to promote the boisterous and profane behaviors exhibited by people who were addicted to alcohol.
In the early 20th century, a popular theory of alcoholism was that it was passed down through the family and got worse with each generation. During that time, a number of politicians proposed legislation that would forbid marriage and require the sterilization of people who were addicted to alcohol in order to “save the next generation.” Fifteen states had passed such laws by 1922, and even states that didn’t require sterilization pressured institutionalized alcoholics—especially women—to undergo the procedure.
In the 1940s and 1950s, doctors incorrectly thought that alcoholism was caused by a dysfunctional endocrine system and believed that injecting adrenocorticotropic hormones would help stabilize it to end alcohol cravings. It didn’t.
By the time the 1950s were in full swing, ending alcoholism was considered a job for prisons and insane asylums, where conditions were often appalling and treatments horrifying. Between 1948 and 1952, frontal lobotomy was used as a method of treatment for those addicted to narcotics, but the practice was discontinued when it was found to be ineffective.
Early Models of Addiction
Today, addiction is widely considered to be a chronic and relapsing disease of the brain that requires medical attention, but it wasn’t always so.
According to Indiana University, by 1960, over 200 theories and definitions concerning addiction were widely touted, but none were comprehensive and many perpetuated harmful attitudes toward addiction that shaped how the public regarded it and those who suffered from it.10
Moral models suggested that a spiritual deficit and lack of personal responsibility were at the heart of addiction. Although an enormous body of research has debunked the claims of moral models, they still influence the way addiction is regarded today. These models do little more than imbue addicted people with shame and make them less likely to seek treatment for addiction.
The temperance model blamed alcohol itself for the high prevalence of alcoholism. It viewed alcohol as an extremely dangerous drug and stressed that total abstinence was the only way to avoid catastrophic problems and surefire death. The temperance movement was instrumental in passing the 18th Amendment, marking the beginning of Prohibition.
Characterological models promoted the idea that personality deficits were the cause of addiction. Its proponents believed that people who have addictions are trapped at a particular stage of personality development, and they cited low self-esteem, latent homosexuality and gender role issues as the heart of addictive behaviors.
Educational models cite drug abuse as the result of a lack of education about the harmful effects of drugs and alcohol and maintain that education is essential for helping people understand the devastating effects of drug abuse and come to the decision to stop using. Educational models have a large part in modern treatment, which draws on comprehensive education to help people with addictions understand the mechanics of addiction and relapse to promote long-term recovery.
Other popular models included the conditioning model, which asserted that addiction is a pattern of learned behaviors; biological models that considered genetic and biological factors as the root of addiction; and general systems models that cite social and family dysfunction as the cause of addiction.
Treating Addiction in Modern Times
Today, the American disease model is the most widely accepted theory of addiction among experts and medical professionals. The disease model postulates that addiction is a chronic disease that, much like diabetes and heart disease, can be diagnosed, observed, understood and treated. Like other chronic diseases, addiction can be sent into remission.
Although personal choice is initially a factor for drinking or using drugs, once brain function changes as a result of chronic drug abuse, choice no longer plays a role. Experts define addiction as compulsive drug use despite negative consequences. The addicted brain is now wired to seek out drugs no matter what, and comprehensive treatment is almost always needed in order to restore normal brain function and address self-destructive behaviors so that maintaining abstinence becomes easier over time and the risk of relapse is dramatically lowered.
But abstinence isn’t easy to come by. According to the National Institute on Drug Abuse, willpower and good intentions are rarely enough to overcome an addiction.11 Treatment is an essential part of recovery.
A modern, high-quality comprehensive rehab program takes a holistic approach to treatment that addresses issues of body, mind and spirit. These issues may include legal or financial troubles, medical problems, problems with relationships, mental illness and dysfunction within the family system. Treatment strives to address all of the needs of an individual.
Therapy is at the heart of modern treatment. Through cognitive-behavioral therapy and other traditional and alternative therapies, clients learn to evaluate their thoughts, beliefs, attitudes and behaviors and replace those that are harmful with those that are healthier. They develop a toolkit of skills and strategies for coping with triggers like stress and cravings, and they identify high-risk situations and formulate an effective plan for avoiding or coping with them. Through comprehensive therapy, clients improve their self-esteem, identify purpose in life and make meaningful lifestyle changes that promote long-term successful recovery.
The Principles of Effective Treatment
The National Institute on Drug Abuse has developed the Principles of Effective Treatment, a set of tenets that should guide any quality treatment program.12 The 13 principles include acknowledging that:
Addiction is a complex but treatable disease that affects brain function and behavior, resulting in changes that persist even after drug use is discontinued.
No single treatment is right for every individual. There are many pathways to recovery, and each individual will require different types of therapies, interventions and services in order to successfully treat the addiction.
Effective treatment addresses the multiple needs of the individual, not just the addiction. Treatment must address any legal, medical, psychological, vocational and social problems, and it needs to be appropriate for an individual’s age, culture, gender and ethnicity.
Staying in treatment for an adequate period of time is essential for successful recovery. Research shows that most people need at least three months in treatment to effectively stop or reduce their drug use. The longer the duration of treatment, the more successful the outcome.
Behavioral therapies, including group, individual, and family therapy, are the cornerstones of drug abuse treatment.
Medication is an essential element of treatment for many individuals, especially for those with severe alcohol or opioid addiction, but medication should be used in conjunction with counseling for the best possible outcome.
An individual’s treatment plan needs to be continually assessed to ensure it meets changing and emerging needs. Any co-occurring mental illnesses must be addressed at the same time as substance abuse through integrated treatment.
There Is Hope
Our understanding of addiction and what makes treatment successful has come a long way in the past 150 years. Today, recovery is approached with a positive attitude and promoted through research-based, best-practices treatment methods.
According to the Substance Abuse and Mental Health Services Administration, hope is the foundation of recovery.13 Hope is the belief that a better future is possible, that the challenges of abstinence can be overcome and that recovery is built on an individual’s strengths, coping skills, talents, resources, and inherent values.
Through treatment, long-term recovery is possible. It takes hard work, but the work is rewarded exponentially through better self-understanding, a keener sense of well-being and a dramatically higher quality of life.
Alcoholism is Not a Disease. (n.d.). Retrieved from http://www.baldwinresearch.com/alcoholism.cfm#sthash.WeTiyeqT.GVQ5iFx7.dpuf
Blocker, J. S. (2006, February). Did Prohibition Really Work? Alcohol Prohibition as a Public Health Innovation. American Journal of Public Health, 96(2), 233-243. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470475/
Facts About Alcohol. (2015, July 25). Retrieved from https://www.ncadd.org/about-addiction/alcohol/facts-about-alcohol
America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. (2014, May 14). Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse
What is the Scope of Cocaine Use in the United States? (2016, May). Retrieved from https://www.drugabuse.gov/publications/research-reports/cocaine/what-scope-cocaine-use-in-united-states
Motel, S. 6 Facts About Marijuana. (2015, April). Retrieved from http://www.pewresearch.org/fact-tank/2015/04/14/6-facts-about-marijuana/
Saad, L. (2013, August 2). In U.S., 38% Have Tried Marijuana, Little Changed Since ’80s. http://www.gallup.com/poll/163835/tried-marijuana-little-changed-80s.aspx
Admissions Aged 12 and Older, by Primary Substance of Abuse: Number, 2003-2013. (2015, January 23). Retrieved from http://www.samhsa.gov/data/sites/default/files/2013_Treatment_Episode_Data_Set_National/2013_Treatment_Episode_Data_Set_National_Tables.html
Keeley Institute. (n.d.). Retrieved from https://library.ndsu.edu/fargo-history/?q=content/keeley-institute
Engs. R. C. (n.d.). Controversies in the Addition’s Field. Retrieved from http://www.indiana.edu/~engs/cbook/chap1.html
Drug Facts: Understanding Drug Abuse and Addiction. (2012, November). Retrieved from https://www.drugabuse.gov/publications/drugfacts/understanding-drug-abuse-addiction
Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). (2012, December). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
Recovery and Recovery Support. (2015, October 5). Retrieved from http://www.samhsa.gov/recovery