History Of Substance Abuse Treatment

Historical and literary accounts have long documented individual attempts to draw back from the abyss of alcohol and drug abuse. At various times autobiographical, biographical, journalistic, and anecdotal, these descriptions list centuries-old recovery methods still employed today in lay and professional settings. Modalities include gradual decrease in dosage; symptomatic use of nonad-dicting medications; isolation from the substance; relocation away from fellow users; religious conversion; group support; asylum in a supportive and non-demanding environment; and treatment with a variety of shamanistic, spiritual, dietary, herbal, and medicinal methods (Westermeyer, 1998).

Beginning with Galenic medicine, a key strategy has been to identify certain syndromes as having their etiology in alcohol and drug abuse. Once the etiology is determined, the specific treatment (i.e., cessation of substance abuse) can be prescribed. Examples of such substance-associated disorders include delirium tremens (i.e., alcohol and sedative withdrawal), withdrawal seizures, morphinism (i.e., opioid withdrawal), cannabis-induced acute psychosis, stimulant psychosis, and various fetal effects, such as fetal alcohol syndrome. Thus, description of pathophysiological and psychopathological processes, together with diagnostic labeling, has been a crucial historical step in the development of modern assessment and treatment for substance use disorders (Rodin, 1981).

Modern treatment approaches have their origins in methods developed by Benjamin Rush, a physician from the Revolutionary War era, who is often credited as the father of American psychiatry. Rush developed a categorization of drinkers and alcoholics. He further prescribed treatment that consisted of a period of "asylum" from responsibilities and from access to alcohol, to take place in a family-like setting, in a milieu of respect, consideration, and social support. As Rush's concepts were extrapolated to the growing American society, large state-supported institutions were developed—although some smaller, private asylums or sanitoria for alcoholics have persisted up to the current time (Johnson & Westermeyer, 2000).

Medical treatments can interact constructively with cultural factors. For example, taking disulfiram can serve as an excuse for Native American alcoholics to resist peer pressures to drink (Savard, 1968). Ethnic similarity between patients and staff appears to be more critical to the treatment process than in other medical or psychiatric conditions (Shore & Von Fumetti, 1972). Strong ethnic affiliation may be associated with more optimal treatment outcomes, although ethnic affiliation may change as a result of treatment (Westermeyer & Lang, 1975).

On a federal level, treatment for drug abuse (largely opiate dependence) began with the Harrison Act of 1914, which outlawed nonmedical use of opiate drugs. For a time, heroin maintenance was prescribed and dispensed in several clinics around the country. Although research studies were not conducted, case reports from these clinics indicated that many patients were able to resume stable lives while receiving maintenance doses of heroin. These clinics were phased out, largely because of political opposition. Two long-term, prison-like hospitals for opiate addicts were established (one in Kentucky and the other in Texas). Research in these institutions contributed greatly to our understanding of opiate addiction (and alcoholism, which was also studied), but the demonstrated inefficacy of prison treatment led to their demise as treatment facilities. These legal and medical approaches, beginning in 1914, were effective in reducing opiate dependence in the societal mainstream. However, certain occupational, geographical, and ethnic groups continued to use drugs that were made illicit by the Harrison Act. These included seamen, musicians, certain minority groups, and inhabitants of coastal-border areas involved in smuggling (e.g., San Antonio, Texas; Louisiana seaports; San Francisco, California; and New York City).

Following World War II, medical and social leaders were more aware of widespread mental disabilities in the country because of the high rate of psychiatric disorders among inductees and veterans. This led to the establishment of the National Institute of Mental Health (NIMH), which had divisions of alcoholism and drug abuse. By the 1970s, it became apparent that substance use disorders were widely prevalent. Numerous indices of alcohol abuse and alcoholism had been increasing since World War II, including hepatic cirrhosis and violence-related mortality. Endemic abuse of cocaine and opiates exploded into an epidemic in the late 1960s, followed by the appearance of stimulant and hallucinogen abuse. It was evident that the NIMH was not adequately addressing either the alcohol epidemic or the drug epidemic. This led to the formation of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA), both of which have equal status with the NIMH under the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). Located within the Department of Health and Human

Services, ADAMHA has fostered the development of substance abuse research, training, clinical services, and prevention. Governmental support for these efforts has come largely from elected officials who have personally experienced psychoactive substance use disorders, either in themselves or in their families. For example, most of the last several American presidents have had a spouse, parent, sibling, offspring, or personal experience with a substance abuse disorder.

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