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The history of addiction and addiction treatment

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If you engage in any form of social media these days, you’re more than likely to run across a long-simmering debate over the nature of addiction and addiction treatment.

Throughout recorded history, addiction has ricocheted back and forth between two schools of thought: Is it a choice brought on by the moral foibles and poor decisions of the afflicted, or is it a legitimate illness that can be addressed through medical and psychiatric approaches?

Marc-Antoine Crocq, in a 2007 article for Dialogues in Clinical Neuroscience, documented many early instances of man’s use of mind- and mood-altering substances throughout history: “Tradition has it that Ethiopian priests started roasting and boiling coffee beans to stay awake through nights of prayer after a shepherd noticed how his goats were frolicking after feeding on coffee shrubs,” he writes. Other notable points of interest include:

  • The mushroom Amanita muscaria, which contains a hallucinogenic compound, has been used in Central Asian religious rituals for at least 4,000 years.
  • Homer’s “Odyssey” alludes to a potion that many Greek scholars believed to be derived from opium, and “there is general agreement that the Sumerians cultivated poppies and isolated opium from their seed capsules at the end of the third millennium BC,” Crocq writes.
  • In the Bible, Noah’s first act upon emerging from the Ark was to plant a vineyard.
  • According to the 1989 publication “The History of Wine,” “the oldest seeds of cultivated vines so far discovered and carbon dated were found in Georgia and belong to the period from 7000 to 5000 BC.”
  • In ancient Egypt, waterlilies known as blue lotus flowers were consumed during ritual celebrations because of their sedative and euphoric properties.
  • Both hashish and coffee were commonly used in the Islamic world, and the latter quickly spread to Europe and to the New World.
  • As fermentation gave way to distillation in Europe, alcohol from cereal grains became more potent, leading to an increase in the impact alcohol had on the health and well-being of those who consumed it.

Ancient alcoholics

It stands to reason that once man discovered the euphoric properties of mind- and mood-altering substances, human nature’s proclivity for excess meant that it was shortly thereafter taken to extremes. In the Epic of Gilgamesh, written about a Mesopotamian king who lived around 2,800 BC, the poem details the wild man Enkidu’s introduction to Sumerian civilization: “’Drink the beer, as is the custom of the land.’ Enkidu ate the food until he was sated / He drank the beer-seven jugs! and became expansive and sang with joy!”

Other famous figures of the ancient world had a proclivity for over-indulgence as well: The Macedonian king Alexander the Great, who built an empire from Greece to India, died at 32, and while the cause is still debated, there’s no doubt that drunken benders contributed to his burning of the great palace of Persepolis (according to Greek historian Diodorus Siculus) and the murder of one of his top officers, Cleitus the Black, who had saved Alexander’s own life. Other historical figures from the Ancient World who had a documented problem with alcohol include:

  • Attila the Hun, who may have died in 453 from esophageal varices brought on by heavy drinking;
  • Alcibiades, an Athenian general during the Peloponnesian War, described as a drunken lout in Plato’s “Symposia”;
  • Mark Antony, whose hedonism lost him the favor of Julius Caesar;
  • Roman emperors who ruled hard and partied hard, including Claudius, Nero, Tiberius and Caligula — according to a 2006 article in Current Psychiatry, “Some historians have estimated that two-thirds of Roman emperors who reigned from 30 BC (Augustus) to 220 AD (Elegabalus) drank heavily.”

As alcohol’s effects on those who overindulged became more of a societal problem (some historians attribute the fall of the Roman Empire to, at least in part, the Romans’ love of wine), ancient philosophers began to examine the role free will played in its development. In an article titled “The History of Rehab” by J.R. Thorpe, the author notes that the “first discussion about potential addiction in history likely belongs to the philosopher Aristotle, but he didn't exactly place the blame in a way modern thinkers would advocate. Artistotle believed that alcoholism, an excessive dependence on a substance, was the fault not of the substance itself, but of the will of the addicted person. He called the problem ‘akrasia,’ or ‘incontinence of will’: people who were akratic couldn't control themselves enough to be able to stop imbibing.”

Ironically, the juxtaposition of the two views — disease vs. choice — was at least alluded to even then, for Aristotle’s teacher, the philosopher Plato, pointed out the physical effects of wine in a collection of his writings known as “Laws”: “The first is a reference to a Carthaginian law ‘which ordains that no soldier on the march should ever taste of this potion [wine], but confine himself for the whole of the time to water drinking only,’” according to a 1999 article in the Oxford Academic by Ernest L. Abel: “The second is a statement Plato made advising parents to be sober when they procreate children since: ‘… it is not right that procreation should be the work of bodies dissolved by excess of wine, but rather that the embryo should be compacted firmly, steadily and quietly in the womb.’”

The Middle Ages

As the Roman Empire began to decline and Christianity began to spread throughout Europe, the Roman Catholic Church — the predominant religious authority of the time — sought to strike a balance between moderation and intemperance. Wine was declared to be a gift from God, and while individuals were allowed to decide on their personal consumption, overindulgence was considered sinful, and according to researcher J.D. Rolleston, “taxation of drink, reduction in the hours of sale and the number of taverns and other restrictions were introduced in the Middle Ages,” according to a 1933 article in the publication Nature.

A number of factors led to a generally agreed-upon increase in drunkenness during the Middle Ages, however: pagan “feast traditions” that resembled Roman Bacchanalian celebrations and carried forward into more civilized times, harsh lifestyles from which solace was sought through alcohol and a need for nutrition that could sometimes only be obtained through the carbohydrates offered in beer.

Alcoholics were often perceived as men (and women) of low character, and in some cases were jailed, tortured and executed for being possessed by demons. Elsewhere in the developing world, other methods were used in an attempt to curb addiction: “In the 1600s, smoking was punishable by beheading in the Ottoman Empire and by lip-cutting in Russia, while anybody smoking hashish in 14th-century Egypt would face the much more benign strategy of having their teeth pulled out,” according to Crocq.

By the 1600s, when Europeans sailed west to colonize the Americas permanently, they took their love of alcohol with them. According to W.J. Rorabaugh, writing in 1991 for the Organization of American Historians publication Magazine of History, “English colonists in Massachusetts and Virginia imported beer, but this was expensive, and for a time they brewed their own. After 1700 the colonists drank fermented peach juice, hard apple cider, and rum, which they imported from the West Indies or distilled from West Indian molasses.”

Rorabaugh goes on to write that “practically everyone drank,” and that candidates who ran for local office stood almost no chance of winning without giving away free alcohol. Even toddlers were proffered the “sugary dregs of their parents’ rum toddies,” according to history writer Livia Gershon, and when the British refused to sell Americans its Caribbean-controlled rum after the Revolution, farmers with a glut of corn began to produce whiskey. Whiskey was produced in such large quantities that it was cheaper than beer, coffee or milk, and by 1830, residents of the United States older than 15 drank on average seven gallons of alcohol per year.

It was during this period that some individuals began to see that alcohol addiction would plague their new country just as it had the Old World.

The New World

Benjamin Rush, one of the signers of the Declaration of Independence, was a pioneer of American addiction medicine. Although he believed, as most physicians of his day did, that treatments such as bleeding and purging with mercury would “cure” insanity, he also took a number of revolutionary positions, such as an advocacy of occupational therapy: In his 1812 book “Medical Inquiries and Observations, Upon the Diseases of the Mind,” he wrote, “It has been remarked that the maniacs of the male sex in all hospitals, who assist in cutting wood, making fires, and digging in a garden, and the females who are employed in washing, ironing, and scrubbing floors, often recover, while persons, whose rank exempts them from performing such services, languish away their lives within the walls of the hospital.”

Communal therapy was already embraced by Native American tribes, who found their own ranks decimated by the introduction of alcohol to the New World. Writing for The Fix in 2015, Jodi Sh. Doff notes that “in the 1750s, ‘sobriety circles’ were formed in Native American tribes across the country. In the tradition of ‘wounded healers’ — the belief that recovery from a devastating illness is a sign of a healer — Native American sobriety circles were led by tribe members who’d survived their own battles” with alcoholism.

Their experience, strength and hope led them to use “their own recoveries from alcoholism to launch abstinence-based movements that called for the complete rejection of alcohol and a return to ancestral traditions.” In some instances, Native peoples converted to Christianity espoused religious conversion to overcome alcoholism, and Puritanical ministers in New England declared public drunkenness a sin. Early attempts to rein in alcohol consumption were largely ineffective, but the temperance movement began to shape public policy in the fledgling country, and by 1850, half of Americans had given up alcohol, according to Gershon.

During that same period, advances in science began to show medical practitioners that prolonged and abundant alcohol consumption had a devastating effect on the human body, and in the mid-1800s, Swedish physician Dr. Magnum Huss coined the term “alcoholism.” According to authors Alana Henninger and Hung-En Sung, writing in the paper “History of Substance Abuse Treatment,” “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.”

The 19th Century

One of the first patient advocate organizations was the American Association for the Cure of Inebriation, organized in 1870 by the managers of six homes and asylums for alcoholics. They pushed for alcoholism to be treated as an illness rather than a vice or a criminal activity, and these “inebriate homes” and asylums served as refuges for those who battled with alcoholism. One of the first, the New York State Inebriate Asylum, opened in 1864.

At the same time, the nation began to see a drastic increase in the number of individuals addicted to morphine, which was distributed liberally to wounded soldiers during the Civil War. Horace B. Day, writing in the 1868 publication “The Opium Habit,” estimated that 80,000 to 100,000 Americans were addicted to opium, and one Union soldier held prisoner at Andersonville and given morphine upon his release described in stark detail what happened when he attempted to quit: “No tongue or pen will ever describe … the depths of horror in which my life was plunged at this time; the days of humiliation and anguish, nights of terror and agony, through which I dragged my wretched being,” he wrote in the 1876 publication “Opium Eating: An Autobiographical Sketch by a Habituate.”

As morphine began to be widely used in pain management, physicians ignorant of its addictive properties began to notice its euphoria alleviated depression and sadness. As a result, the combination of wounded veterans and a shattered citizenry — especially in areas like the South, where one in five young men had died in the conflict and entire cities had been burned to the ground — made for a ready population of burgeoning addicts.

Opium, too, was thought to have medicinal purposes in the ongoing search for a cure for alcoholism. A number of questionable therapies, in fact, made the rounds in those days, what could arguably be considered the “Wild West” of addiction treatment, according to Thorpe: “How you were treated, though, depended very heavily on whether you were socially well-connected or relatively poor. The wealthy could get away with confinement at home and private treatment, much of which was slightly ludicrous: aside from the misguided marketing of morphine as a treatment for alcohol addiction, there are also records of private patients inhaling amyl nitrate or, in the case of a friend and patient of Sigmund Freud's, cocaine. Chronic addicts of lower social status, though, were prone to being shut up; and the options were rarely salubrious. Jails, almshouses for the poor, hospitals, and insane asylums all received their share of addicts, though private hospitals often refused to house ‘inebriates’ because it was seen as a waste of resources.

“When institutions did start to form in the U.S. in the late 1870s, called things like ‘homes for the fallen’ and ‘inebriate asylums,’ their treatment regimes were, well, interesting. The usual treatments in an institution involved isolation and ‘detoxification,’ a bewildering and slightly dangerous process involving the administering of everything from poisonous belladonna to the hypnotic drug chloral hydrate.”

The 20th Century

By 1902, there were more than 100 facilities around the country for the treatment of alcoholism, perhaps the most popular springing from the ideas of Dr. Leslie E. Keeley. According to the North Dakota State University Archives, “The Keeley Institutes were franchise facilities for the treatment of addiction to alcohol, nicotine and narcotic drugs,” and one of the first institutions to treat alcoholism as a disease. Although the “Keeley Cure” was a dubious cocktail — strychnine, gold and alcohol — it was so well-known at the time that it was parodied in music, and by the 1890s, there was a Keeley Institute in almost every state and country.

By the end of the century, “Dr. Keeley had founded over 200 treatment centers, where patients were given the secret ‘cure’ in the form of injections,” according to the NDSU Archives. “Surprisingly, these centers had a 50 percent success rate. People who recovered from their problems stayed well because in addition to the seemingly useless injections … Dr. Keeley encouraged group therapy and the exchange of information, as well as getting community involvement. These groups were a precursor to the groups of today, such as Alcoholics Anonymous.”

In addition, the passage of the Harrison Act in 1914 put an end to the sale of products containing ingredients derived from opium poppies or coca leaves, meaning that tinctures, powders, elixirs and various other “cure-alls” that could be bought in catalogs and at pharmacies were no longer for sale legally. The black market began to pick up the slack and has continued to do so ever since, but with addiction pushed underground — and alcoholism soon to follow thanks to the 18th Amendment and the advent of Prohibition — addiction treatment suffered.

By the 1920s, only 11 Keeley Institutes survived, and the “out of sight, out of mind” thinking in regards to drugs and alcohol served to hurt those who needed help the most: “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,” according to Henninger and Sung.

The Harrison Act was designed to curb the unregulated access to what were perceived as dangerous drugs, but it had unintended consequences as well. Although opium and cocaine derivatives were only allowed to be prescribed by physicians, doctors were prohibited by law from prescribing them to addicts for the purpose of detoxification or maintenance, “because the government believed too many addicts were remaining on maintenance programs indefinitely rather than being weaned off of drugs,” Henninger and Sung continue. In addition, morphine maintenance clinics that first opened in 1912 to treat the rise in addicted individuals all but disappeared, and almost overnight, the issue of addiction shifted from a public health issue to a criminal justice one:

“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 drug-related incarcerations increased from 63 to1,889. 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,” Henninger and Sung write.

The modern era

"The Man on the Bed," painting of Bill Wilson and Dr. Bob Smith by A.A. member Robert M., published in the 1955 edition of Grapevine.

The approach shifted once again beginning in 1933, once Prohibition ended and the Modern Alcoholism Movement began to take hold. Bill Wilson and Dr. Bob Smith are credited with birthing the 12 Step model of recovery in 1935 with the advent of Alcoholics Anonymous, and according to Thorpe, “After the Second World War, Alcoholics Anonymous only got more popular, and "twelfth step houses," often in residential areas, grew rapidly across America. They emphasized a totally sober environment and held regular AA meetings for inhabitants and outsiders, a practice that still continues.”

And in 1949, the biggest step forward in the field of addiction treatment was established via the Hazelden Foundation. Previously, an alcoholic faced three prospects: institutionalization with others suffering from extreme psychiatric disorders; a life of crime and jail; or a life of destitution and homeless, all of which were viewed through a prism of judgment on the afflicted’s moral compass.

The Minnesota Model, as it’s called began as a social reform movement in which a “guest house” concept for alcoholic men in Center City, Minn., began modestly — seven men and three staff members — with a unique approach to behavioral health therapy: “behave responsibly, attend lectures on the Twelve Steps of Alcoholics Anonymous, talk with the other patients, make your bed, and stay sober,” according to the Hazelden Betty Ford Foundation’s website.

“It would be easy to dismiss such a program,” the website continues,” yet behind these simple rules was a wealth of clinical wisdom. All five rules focused on overcoming a common trait of alcoholics — something the founders of AA described as ‘self-will run riot.’ People addicted to alcohol can be secretive, self-centered, and filled with resentment. In response, Hazelden's founders insisted that patients attend to the details of daily life, tell their stories, and listen to each other. The aim was to help alcoholics shift from a life of isolation to a life of dialogue.”

Such an approach is now a cornerstone of most recovery fellowships: “The therapeutic value of one addict helping another is without parallel,” it states in the Narcotics Anonymous literature. As the program’s success grew, organizers began to draw on principles established at another Minnesota facility, the Willmar State Hospital: that alcoholism exists; that it is a disease; and that it is a multiphasic illness.”

By 1956, the American Medical Association had declared alcoholism a disease, a revolutionary idea that grew more widespread with the publication of the 1960 book, “The Disease Concept of Alcoholism,” by E.M. Jellinek. Over the past 50 years, other professional medical organizations have followed in the AMA’s wake, and today those three primary approaches — the disease concept, the 12 Step process and the Minnesota Model of treatment — continue to offer addicts and alcoholics the best change at peaceful and serene long-term recovery.