**2. Early roots of treatment in the United States**

The treatment of substance-related problems in the United States came from the intersection of various forces in the middle of the nineteenth century. Patterns of alcohol and other substance use, social reform movements, regulatory efforts, and the dynamics of professio‐ nal guilds all combined to shape the beginning of attempts to intervene with these problems. Both the Europeans on the North American continent and the Africans who were brought as slaves were users of alcohol, but the Native Americans were mostly *not* users of alcohol. Cultural factors were significant and patterns of usage and resulting problems, including the catastrophic effect of alcohol on Native American tribes [3]. As colonization progressed, public drunkenness may have been the most significant problem that was explicitly identified [4]. Benjamin Rush (1746–1913) was an influential writer on a number of subjects, having been a member of the Continental Congress, a signer of the Declaration of Independence, and notable hospital reformer of the eighteenth century. Rush's work was rich with descriptions of alcohol use as a progressive *medical* condition that required abstinence as a method of invention. Until the influence of his writings, alcohol had previously been seen as a moral problem or a manifestation of mental illness [4].

#### **2.1. Temperance**

The American temperance movement emerged as alcohol-related problems became more salient. As one might discern from the name of the organizations ("Temperance"), the initial goals were to promote moderate use. However, the goals of the temperance movement changed to a perspective that emphasized abstinence [5]. While modern abusers of substan‐ ces must battle for recovery in the context of a variety of possible interventions, substance abusers in the nineteenth century had far fewer alternatives. There is evidence that these persons turned to a variety of social change movements and were met with various attitudes. For example, the political attitudes of temperance movement participants could sometimes be confused with other political stances (e.g., slavery). Thus, factors that were associated with the rise and fall of various social movements were also critical to attempts to establish programs to assist substance users (primarily alcoholics at that time).

#### **2.2. Institutional treatment**

destructive effects of substance use. The vast social issues include, but are certainly not limited to moral, legal, ethical, economic, political, sociological, and psychological considerations. So, it is virtually impossible to be exhaustive in one's review of these issues, and this chapter will

Modern data indicate that substance use and misuse continue to be widespread [2]. For 2014, nearly 140 million people over the age of 12 used alcohol, more than 60 million reported some binge drinking, and more than 16 million people reported heavy binge drinking in the United States. Estimates for the use of illicit drugs overall appear to be overshadowed by data pertaining specifically to marijuana use. More than 22 million people reported use of mari‐ juana, nearly 67 million reported use of tobacco, and more than 4 million persons reported misuse of prescription medication. Perhaps of greater concern than the reported patterns of use overall is the reported 17 million people whose self-reported use is consistent with a diagnosis of an alcohol use disorder and more than 21 million people whose self-reported use is consistent with a diagnosis of a substance use disorder. Clearly, misuse of psychoactive

The treatment of substance-related problems in the United States came from the intersection of various forces in the middle of the nineteenth century. Patterns of alcohol and other substance use, social reform movements, regulatory efforts, and the dynamics of professio‐ nal guilds all combined to shape the beginning of attempts to intervene with these problems. Both the Europeans on the North American continent and the Africans who were brought as slaves were users of alcohol, but the Native Americans were mostly *not* users of alcohol. Cultural factors were significant and patterns of usage and resulting problems, including the catastrophic effect of alcohol on Native American tribes [3]. As colonization progressed, public drunkenness may have been the most significant problem that was explicitly identified [4]. Benjamin Rush (1746–1913) was an influential writer on a number of subjects, having been a member of the Continental Congress, a signer of the Declaration of Independence, and notable hospital reformer of the eighteenth century. Rush's work was rich with descriptions of alcohol use as a progressive *medical* condition that required abstinence as a method of invention. Until the influence of his writings, alcohol had previously been seen as a moral problem or a

The American temperance movement emerged as alcohol-related problems became more salient. As one might discern from the name of the organizations ("Temperance"), the initial goals were to promote moderate use. However, the goals of the temperance movement changed to a perspective that emphasized abstinence [5]. While modern abusers of substan‐ ces must battle for recovery in the context of a variety of possible interventions, substance abusers in the nineteenth century had far fewer alternatives. There is evidence that these

focus only on the highlights of treatment of substance use conditions.

144 Recent Advances in Drug Addiction Research and Clinical Applications

substances remains a significant problem.

manifestation of mental illness [4].

**2.1. Temperance**

**2. Early roots of treatment in the United States**

Because of the difficulties associated with substance misuse, attempts have been made to provide shelter for persons who needed some form of assistance. These efforts to provide residential care have been referenced in writings as long as 5000 years ago [6]. By the early 1800s in the United States, the physical effects of alcohol were becoming clearer, and there was a significant increase in the number of institutions that emphasized the treatment of alcohol and other addictions [7].

Just as the public response to substance abuse was a product of complex forces, complex forces were also significant to treating institutions. Economic forces, primitive clinical methods, conflict within the field, and problems associated with individual behavior all contributed to a decline in the institutional treatment movement. It was clear by the mid-1800s that the search was on for more effective approaches to treating addictions. Not surprisingly, miracle cures were suggested in the context of entrepreneurialism. Innumerable chemical preparations and marketing techniques were seen [8]. The first "inebriate asylum" was called for by Dr. Samuel B. Woodward, whose efforts led to the establishment of the first real institutional treatment in the form of the New York State Inebriate Asylum, established in 1864. The first facility for women was the Martha Washington Home in Chicago that was established in 1867. Further progression in institutional care as part of the moral treatment that Dr. Woodward espoused was slow to grow.

#### **2.3. The increase in legal controls**

The sentiment of many Americans seemed to have been critical of the non-medical use of any drug, including alcohol and tobacco. From colonial times through the Civil War, these attitudes were associated with abstentionist outcries against alcohol and tobacco and calls for regula‐ tion. The regulation of substance use has been increasingly relevant to treatment since the proliferation of public regulations in the early 1900s. However, the energy expended to stem the availability and use of psychoactive substances has met with controversy. The specific consequences of both direct and indirect action included the intention to eliminate use, pressure to make the price of substances rise, and efforts to reduce social costs of use [9]. History has been clear that race, ethnicity, and social class have been highly tied to efforts to control substance use and that legal controls frequently represented bigotry and oppression that served the aims of dominant groups.

The path to regulation began with registration and taxation mandates. The first significant step in this regard was the Pure Food and Drug Act of 1906. At time in which there had been decades of proliferation of substances and their combination in Patent Medications, the Pure Food and Drug Act established the requirement that medications with opiates and other drugs must provide a list of ingredients. This made opium and cocaine were early casualties of regula‐ tion attempts [10].

The Harrison Narcotic Act was passed in 1914 by the United States government. The origi‐ nal intention of the bill was to place a special tax on opium and coca, but the effect was to eliminate legal opiates. Alcohol and tobacco were also soon to be subject to growing legal pressure. Tobacco was not traditionally used in the form of modern cigarettes, but tobacco habits were fostered by the development of modern cigarettes, leading to large increases in tobacco use between 1900 and 1910.

The battle over alcohol was even to be more visible and controversial. Andrew Volstead of Minnesota saw his name attached to the Eighteenth Amendment to the United States Constitution. The result of the "Volstead Act" (H.R. 6810) was that from 1920 until 1933, and the manufacture, sale, and consumption of alcohol were prohibited in the United States. The failure of prohibition leads to the Twentieth Amendment that repealed federal prohibition in 1933. The states gradually repealed their own legislation ending with Mississippi in 1966.

As one alternative to the futility of broad prohibition, legally mandated treatment for substance abusers is now widely practiced [11], and legally mandated treatment is seen as a sensible approach for persons whose criminal offense is substance related. The intention is to direct the convicted individual to a system in which treatment is a more central focus then would be expected in a traditional correctional context. Critics of the approach question the propriety and efficacy of this strategy.

#### **2.4. Spiritual traditions and intervention**

Another common perspective on treatment of substance-related problems emerged from spiritual traditions. Spiritual traditions provided the foundation for a variety of approaches to substance-related problems. Some of this influence has been direct and some indirect. For example, a movement as broad as the American temperance movement was substantially derived from the evangelical movement. The Benjamin Rush speculated that religion by itself could "carry the day" with substance abusers [12]. The early view that religious experiences were an important path to recovery was bolstered by the perspectives of some early mental health professionals. Some professionals in health care were skeptical of religious ap‐ proaches and others opined that religious approaches were only good for certain patients. Even within psychology, there were advocates for spiritually based intervention. The prominent work of George Cutton's *The Psychology of Alcoholism* (1907) and the broad work of the pragmatist William James (non-practicing M.D. and Harvard psychologist) went far to legitimize the spiritual view. James was well known because of the variety of his contribu‐ tions related to psychology. James operationalized the center of religious conversion as anti-Christian by referring to it as "the hot place in a person's consciousness … The habitual center of one's personal energy ([13], p. 196)." Despite knowing that reports of religious conversion experiences would be met with skepticism in a professional community of materialists, James felt that the results or specific components of spiritual interventions should be considered independent of the underlying assumptions of a particular spiritual perspective. The contin‐ ued significance of the spiritual contribution to substance abuse therapeutics is reflected in a number of contemporary realities. The United States Congress passed a measure in 1996 that allowed states to contract with faith-based programs in substance abuse treatment. This led to an increase in emphasis on such programs and associated research into the effectiveness of such approaches [14, 15]. Typically, such programs include Bible study, church services, spiritually based therapy, in addition to a strict regimen of activities. There are continued efforts to clarify the precise nature of treatment that is based on Christian principles [16].