Addiction Treatment: Then and Now
While treatment for substance use disorders may be a relatively new development, the problem is not, as evidenced by “Noah plants a vineyard, is drunken and mocked by Ham” (Luke 21:34 New International Version). Addiction treatment has a relatively short history when compared to treatment of other illnesses. The basis of much of today’s treatment started with in 1935 with the creation of Alcoholics Anonymous, which was an outgrowth of the Oxford Movement.
Early on, there were many beliefs that had disastrous consequences. One was that “You can’t help an alcoholic until the alcoholic asks for help,” which resulted in people standing around waiting while alcoholics drank themselves to death. Another was the belief that alcoholics had to first “hit bottom” before recovery could begin. I recall in the early 1960s, a man came to an AA meeting wearing a suit coat and pants that matched. He was told, based on his appearance, that he was not ready and should go out and drink some more. At that time, many people who came for help did so only when they were at the end of the line, when their disease had progressed to a point where advanced liver disease, Korsakoff syndrome, and Wernicke’s encephalopathy were common. There were also program policies and restrictions that the relatively new counselor would find ludicrous. If potential alcoholic patients had co-occurring mental health disorders, they were either denied admission or if admitted, were immediately taken off their psychiatric medication to be drug free.
Alcoholics and drug addicts (those whose drugs were illicit) were viewed as two distinct populations and were treated in separate facilities. I remember early in my career at an “alcoholism” treatment center, the facility’s clinical advisory board reluctantly permitted us to admit no more than five drug addicts at any one time in a sixty-three-bed rehabilitation facility. Eagleville Hospital near Norristown, Pennsylvania was one of the first rehabs to treat alcoholics and drug addicts together, even in the same group! This was so new that the hospital held an annual conference about treating alcoholics and drug addicts together.
This artificial division was not limited to treatment programs. Most state licensing authorities had separate alcohol and drug agencies. The Pennsylvania Alcoholism Counselors Association (PACA) was tasked with developing counselor certification standards and I was elected chairperson of the group. After many unsuccessful attempts to get the group to develop standards that included both alcoholism and drug addiction counselors, I finally resigned in frustration. The Joint Commission on Accreditation of Hospitals (JCAH) developed the first set of substance use disorder accreditation standards, but it was only for alcoholism treatment programs. Only later did they create a separate set for drug programs.
At a point when insurance benefits for treatment became available—in the mid-1970s—they were based on the then current treatment model which was the twenty-eight-day inpatient rehabilitation facility. No outpatient insurance benefits were available forcing people who had a substance use disorder, regardless of its severity, into inpatient treatment because that was on the only level of care that could be reimbursed. While the common inpatient benefit was twenty-eight or thirty days, one insurer in New Jersey had a benefit package of thirty days for alcoholism and twenty days for drug addiction. I guess they thought that drug addicts recover faster!
In early treatment, with the possible exception of counselors at a methadone programs, alcoholism counselors were almost always recovering alcoholics in AA who shared their strength, hope, and experience. Qualifications to be a counselor were two years of sobriety in AA and the willingness to work cheap. The counselors were not trained clinicians, but these recovering people stepped into the void created when the professional community—including physicians, psychologists, and social workers—abdicated their responsibility to treat alcoholics with the attitude of “Who wants to treat drunks? They smell up your waiting room, don’t follow recommendations, and don’t pay their bills.” If it were not for these early counselors, there is a question about whether we would even have a field today. Early alcoholism counselors were called “paraprofessionals” and paid accordingly.
The field went through the treatment du jour phase, looking for the simple answer to a complex problem. While some of these suggestions might be a helpful addition to psychosocial treatment, they were presented as if they were the magic bullet which would fix the problem. Included were such things as diet, nutritional supplements, acupuncture, ECT, and drugs such as benzodiazepines. A colleague once told me that in the 1960s, some physicians believed that the etiology of alcoholism was a Valium deficiency. My favorite “magic bullet” drug was Flagyl, an antibiotic used to treat vaginitis. It was also prescribed to the male partners of infected women so they would not reinfect the woman when having sexual intercourse. Some of these men who were prescribed the drug had a drinking problem and reported a reduced desire to drink. In addition, when they did drink they experienced a disulfiram-like reaction. Some people applauded this as the new cure for alcoholism!
As an individual with fifty-four years of experience as an addiction clinician, I can attest to the great changes in delivery and types of treatment that have taken place over that period of time. When I first began working at an inpatient program in 1962, there was no patient assessment and therefore no treatment planning. All patients received the same treatment and all treatment programs were fixed length-of-stay and program-driven rather than clinically-driven. “Group therapy” was ten patients sitting in a circle reading and discussing a chapter in the Big Book of Alcoholics Anonymous. Most of the lectures were about the Steps or Traditions of AA. Movies and audiotapes of AA meetings were commonly used. I remember creating a psychoeducational presentation on addiction and sexuality, over which I was almost fired. A member of the advisory challenged me with, “What the hell does this have to do with alcoholism?”
Instead of motivational interviewing, confrontation was liberally used. Patients were wholly immersed in the AA philosophy and way of life. While this would not be considered “treatment” by today’s standards, many patients in these programs not only recovered but later became alcoholism counselors themselves. My explanation for this is that many of these patients manifested a gradual decline into alcoholism over many years; were employed and part of an intact family unless these were lost because of their drinking; were high school and college graduates, some with post graduate degrees; and were without significant co-occurring psychiatric problems. They were sometimes described lovingly as “plain, old, simple drunks.” Clearly, this early “treatment” would be ineffective with today’s patients. Anything that was not AA tended to be regarded as “anti-AA.”
Since early treatment programs had no medical staff, a new industry evolved: the free-standing detoxification program, similar in concept to current free-standing surgery centers. The plan was that patients were taken to the detoxification center and after detoxification was completed, they would be transferred to a rehabilitation program. Unfortunately, many patients never made the transition, deciding after detoxification that they were now “cured.” Continuing care from inpatient treatment consisted of referral to AA and ninety meetings in ninety days. Co-occurring mental health conditions were believed to disappear as a function of sobriety.
Where are we now? We now have earlier intervention as a result of EAP involvement, the use of SBIRT, DUI, and drug courts and other alternatives to incarceration which have brought down the average age of people entering treatment or self-help groups—this a good thing because people are developing problems with substances at earlier ages. We can now intervene in addicts’ lives before they have done irreparable harm to their bodies, minds, and social and family networks. Motivational interviewing has replaced confrontation. The fixed length-of-stay and program-driven treatment is now less common, though not completely eliminated, and where clinically driven, variable length-of-stay exists, it often has been the result of reimbursement restrictions rather than clinical justification. The one size-fits-all inpatient treatment has given way to a range of levels of care. Comprehensive assessment has become routine with the ASAM Criteria providing a system for doing so.
The treatment of patients with co-occurring disorders has become routine, as has the use of psychiatric medications. More recently, we have seen a variety of antiaddiction medications, both agonist and antagonist, and a growing willingness on the part of treatment programs to use them. There is now increasing use of evidenced-based protocols including CBT and contingency management. There has been a professionalization of alcohol and drug counselors with many now holding advanced degrees, certifications, and licensure. We are seeing more outcome research.
In spite of these areas of progress, the challenges of inappropriate restrictions on commercial insurance payments for treatment seem to be getting worse. While public funding is often more generous, there are inadequate resources to treat all who require services. Stigma has been reduced, but not nearly enough. We are also seeing the first steps in integrating addiction services with primary care.
We have come a long way, but only the future will determine whether we have come far enough.