This three-part series explores the evolution of thought regarding addiction, alcoholism and treatment. Part three continues the survey from 1960 and the start of methadone maintenance to today and the Senate approving the Comprehensive Addiction Recovery Act. This and the previous articles owe a debt of gratitude to the work of William White, Ernest Kurtz, Ph.D. and Caroline Acker, Ph.D., whose combined addiction disease chronologies provide a logical, cohesive structure to this debate.
The 1960s begin with white, middle-class kids experimenting with marijuana, amphetamines, cocaine, psychedelics and heroin. Conservatives are apoplectic. This behavior, coupled with the Civil Rights Movement, sexual liberation and leftist thinking, fuels fears the country is going to seed. The consensus: drug laws are misguided.
Two basic ideas emerge regarding the nature of addiction. Behavioral change is the most effective – and becomes the mainstay for – drug treatment. The second idea is the warhorse from the 1920s: the root cause lies in character flaws. Behavioral change therapy gives rise to the use of rewards and punishments in therapy.
Bill Wilson addresses the National Clergy Conference in 1960. He asserts Alcoholics Anonymous never called alcoholism a disease. He compares it to heart disease. There are many heart ailments contributing to heart disease. Alcoholism is an ailment, illness or malady. That same year, E. Morton Jellinek publishes his pivotal work, “The Disease Concept of Alcoholism.” He writes, “The concept of alcoholism as a single disease, a unitary clinical entity based on a medical model, believed to progress along a known or predictable continuum…may be an oversimplified representation.” In short, alcoholism can be a disease without being a disease.
The Community Mental Health Services Act, passed in 1963, calls for the establishment of community-based treatment programs. In 1965, V.P Dole and M.E. Nyswander publish their metabolic disease theory in Journal of the American Medical Association. The theory builds on the work of Mary Jeanne Kreek for methadone maintenance as a treatment for heroin addiction. Methadone maintenance will become an integral part of President Nixon’s community-based addiction policy in the 1970s. It also marks the end of the era of narcotic control policy, roughly in effect since the 1920s. That same year, the American Psychiatric Association recognizes the disease concept of alcoholism.
NARA, the Hughes act and growing support for the disease theory
In 1966, the Narcotic Addiction Rehabilitation Act (NARA) is passed. It represents the first significant federal acknowledgment of medical points of view on addiction. NARA calls for federal funding for community-based treatment programs. The National Institute of Mental Health is tasked with implementing NARA. The Supreme Court upholds Powell v. Texas, which found alcoholism is not a legitimate defense. Justices Marshall, Warren, Black and Harlan reject the disease concept. Later that year, R.E. Reinert and W.T. Brown publish, “Social Drinking Following Treatment for Alcoholism.” The writers present varying accounts of alcoholics who try social drinking. Most fail; some are successful, leading Reinert to publish the same year, “The Concept of Alcoholism as a Bad Habit.” He writes, “We propose that we seriously reconsider the old but common-sense notion that alcoholism is fundamentally a bad habit.”
The ensuing years witness myriad publications debating the accurate definition of alcoholism. In 1969, E. Schmidhofer publishes, “Alcoholism Is Not a Disease.” Later that year, P.W. Haberman and J. Sheinberg publish, “Public Attitudes Toward Alcoholism as an Illness.” The authors cite surveys from 1946 to present day proving the public’s acceptance of the disease concept of alcoholism.
While these salvos cross bows, the number of methadone patients in New York exceeds 4,000 in 1970. Nationwide, 50 methadone programs treat about 10,000 patients.
In 1972, David Robinson publishes, “The Alcoholigist’s Addiction: Some Implications of Having Lost Control Over the Disease Concept of Alcoholism.” In it, Robinson argues Jellenik’s original concept has become so diluted it is now meaningless. Researchers attest the disease concept is in vogue because it gives a better deal to alcoholics, saying it has no scholarly evidence to support it.
The 1970s and ‘80s: NARA and examination of the disease theory
The 1970s and ‘80s prove lucrative for addiction researchers. Hundreds of papers debating every aspect of the addiction phenomenon are published. More practical governance comes from NARA; in 1974, it publishes guidelines for methadone clinics. Throughout the decade, Jellinek is simultaneously pilloried and canonized for solidifying the disease concept.
As AA approaches its 50th anniversary and the medical community is still divided on the disease concept, researchers turn their focus to the concept itself and its culpability. Stanton Peele, in his 1984 article, “The New Prohibitionists,” writes, “The disease theory of alcoholism has the merit of bringing troubled people into the care of hospitals and doctors … Alcoholism may at its roots be a social and cultural problem, not a medical one.”
J.R. Milam publishes, “Disease Concept of Alcoholism” in 1985. The author proudly proclaims, “After some 15 years of surface conflict, the disease concept of alcoholism seems finally to have prevailed over the belief that alcoholism is a symptom of a functional psychological disorder.” The same year, H. Fingarette argues to the contrary. In “Reconceiving Alcoholism,” Fingarette writes, “The governing image of alcoholism as a disease has been shown to be a mistaken oversimplification lacking a satisfactory scientific or conceptual basis.”
As the decade comes to a close, a Gallup Survey Poll finds 87 percent of the public believes alcoholism is a disease and 63 percent believe it is hereditary.
The 1990s, 2000s and CARA
Many of the same players – Peele, Milam, and Fingarette – continue publishing their views into the ‘90s. In 1991, Peele and A. Brodsky publish “The Truth About Addiction and Recovery.” In it, they state 23 reasons why the disease model is detrimental to the individual. Despite the effort devoted to debunking the disease concept or model of addiction, a 2006 Gallup Poll finds 76 percent of Americans believe addiction and alcoholism are diseases.
From the 1900s to the present day, scientists have debated the disease concept and the efficacy of drug treatment. In March of this year, the Senate overwhelmingly approved the Comprehensive Addiction Recovery Act (CARA). This Act represents the most comprehensive legislation regarding the treatment of addiction since 2008. As of this writing, the bill is before the House of Representatives for consideration.
Read the main overview of this timeline as part of our State of Addiction Policy editorial series here. Check back regularly for updates on the campaign at SovHealth.com, Facebook or LinkedIn. You can also follow us on Twitter and the discussion by searching for #StateOfAddictionPolicy and #SovTalk.
About the author:
Darren Fraser is a content writer for Sovereign Health Group. He worked two and half years as reporter and researcher for The Yomiuri Shimbun until they realized he did not read, speak or write Japanese and fired him. Undeterred, he channels his love of research into unearthing stories that provide hope to those dealing with addiction and mental illness. Darren loves the Montreal Canadiens hockey club and horror films and would prefer to enjoy these from the comforts of his family’s farm in Quebec. For more information about this media, contact the author at email@example.com