Addiction Treatment and the Multiple Echoes of History – Lessons to Heed

“If you want a new idea, read an old book” – Ivan Pavlov

In respect to efforts to expand addiction recovery in America, our new challenges often have historic parallels. It is also true that some of the very best ideas we may be able to harness to move our endeavors forward have roots in eras well prior to our own. In this way, rarely are things new under the sun. These dynamics were very much in my mind when I came across William White’s 1999 piece The Collapse of 19th Century Addiction Treatment: Could It Happen Again? The infrastructure he was describing was the first system of care in the US, comprised of programs for inebriates, the term at that time for persons with alcohol addiction, including recovery homes, asylums, private addiction treatment programs and home cures. These programs rose up between 1850 and 1900. There was even the first addiction periodical the Journal of Inebriety which began publication in 1876.

For interested readers, these journals are available for addiction and recovery scholars in the Hazelden Pittman Archives at Hazelden Betty Ford’s Addiction Research Library in Center City MN. It is a national treasure for our field. William White has also preserved the table of contents of the journal which can be found here. There is much for us to learn through examination of this and later attempts to support healing from substance use conditions in an organized fashion. Perhaps most importantly, it is readily apparent that we grapple with very similar challenges 200 years later. The song remains very much the same across the ages. We could learn from our history, but only if we pay attention to it.

Even a casual examination of the history of that era that rose up in the 19^th century in respect to addiction and recovery would reveal what one could consider a free for all. An ecosystem ripe for fraud and abuse at the expense of the vulnerable. Wild, baseless claims about cures, elixirs promising relief containing alcohol, cocaine and opioids. Treatments that were expensive, catered to the wealthy and overpromised what they could accomplish while profiting off the suffering of thousands of people. People who were desperate to try anything at any price to escape the ravages of addiction. The inevitable scandals led to a profound loss of public trust and an erosion in belief that people with substance use conditions were even worth helping. It may have been the first time we had seen this cycle of harm in the name of help hawked by an army of hustlers and hucksters, but it was far from the last. Dynamics I started to write about in similar context of with heavy reliance on the seminal work of William White in two pieces this year, Addiction & Recovery Capitalist – Hustlers Hawking Drugs, Hucksters Selling Recovery in April and in The Devolution of PRSS and the Lost Lessons of Earlier Eras in September of 2024. 

As noted by White, in this paper, the rise of the first addiction field in the 19^th century corresponded with an increase in addiction to alcohol and other drugs, broadly referred to in that era as narcotics. The very first iteration of an addiction treatment field went through a boom and then a bust. He cites multiple factors in the collapse of that system, including:

• An economic downturn that reduced financial support for the efforts that weakened the fields capacity to constructively address internal and external challenges to forward progess.
• A culture shifted away from viewing these conditions as treatable in the broader public sphere, in no small part as a result of the excesses of the fledgling field.
• A focus on viewing addictions from a moral lens and a shift to the criminalization of addiction and legal sanctions.   

When William White wrote the paper in 1999, he saw a number of parallel challenges in our field of 25 years ago. A sea change was occurring in respect to orientation, funding and support for recovery driven by forces both internal and external to the field. What he wrote about in this context in the late 1990s, included:

• The impact of managed care in both the public and private sector resulting in dramatically reduced access to care.
• The shift in focus from healing to criminal justice-oriented interventions that became the primary focus of policy in the 1980s and 1990s and moved away from healing at its core function.    
• Ethical concerns both internal to our field our workforce and the peripheral associated systems that serve to erode public support for treatment efforts.
• The loss of connection to community as over professionalization and institutionalization of the field undermined the vitality of community grounded support that often grew organically and was therefore both robust yet brittle.
• A system with minimal infrastructure and high workforce turnover in part as a result of these cumulative challenges.

William White saw in our care ecosystem weak, fragmented institutions without a cohesive focus on healing. A service system that lacked connection to the authentic community resting on a shallow foundation with a minimal body of evidence to support its claims or to guide its progress forward. He saw profiteering and a focus of effort on those with means that largely ignored care for lower socioeconomic classes. It lacked mechanisms of long-term follow-up to properly support the development and facilitation of services to support the full course of healing beyond acute, short-term treatment. He noted a dearth of states persons to shepherd efforts in the direction that they needed to move and anemic programs and systems vulnerable to colonization by outside interest groups. In light of the challenges he identified, he noted what would need to occur to correct course, avoid a collapse and sustain efforts forward. He penned:

“To prevent such a scenario, we must rebirth the grass roots movement that laid the cultural foundation for the rise of 20th century addiction medicine and the modern system of addiction treatment. We must both aggressively monitor the ecosystem within which we operate and take a more activist role within that ecosystem.  We must get ourselves clinically and ethically recentered. We must take a highly splintered field and find a way to speak with one voice. And we must rebirth a new generation of leaders who can carry our mission of serving the still suffering addict into the 21st century. If we fail to meet these challenges, we may be doomed to repeat an episode in history little known to today’s providers of addiction treatment. And that lack of knowledge is perhaps itself a source of great vulnerability. As the great comedic scholar Lilly Tomlin once suggested, “Maybe if we listened, history wouldn’t keep repeating itself.”” 

We have made some limited progress in the direction he prescribed, in no small part because we did initially focus broadly on grassroots, authentically driven goals while putting aside our differences and keeping our collective eyes on the prize. Yet now, at this moment in history:

• We have largely lost that forward momentum and lack a cohesive, broadly agreed upon focus of efforts.
• A lot of the work we had accomplished through collective effort has eroded as the vision of community driven efforts became just another profit center gained by the industries at the expense of the vulnerable.
• There are a myriad of drugs being marketed in vape shops and elsewhere to people with addictions in ways that cause harm in the name of help, not dissimilar to what occurred in the patent medication era of the 19^th century.
• We have a workforce faced with immense barriers preventing them from actually helping people. They work for dismally low wages mired in red tape, and care is cut too short to be effective. So, they quit. We simply cannot sustain forward momentum without a seasoned and capable workforce, yet turnover rates have never been higher.
• We are further away from universally agreed upon definitions of the pathology and healing from a substance use condition looks like than a generation ago, even as the proliferation of definitions became a cottage industry.
• We have funding systems, credentialing systems and governance processes ripe with profound conflicts of interest.
• Ethical conduct beyond the individual at the institutional level of funders and service providers have never been promulgated, sanctions more properly leveled at how our systems operate focus instead on a few bad apples that are actually in rotten barrels that we ignore in emperor’s new clothes fashion.
• We have our own iteration of a gold rush as treatment is increasingly the focus of venture capitalists and disrupters  more focused on making money than helping people heal. Peer services have become a veritable cash cow for those vying to bill Medicaid and private insurance and maximize revenue for services originally intended to be grounded in community bridging and recovery community capital building.
• Efforts intended to be nestled within the community and not simply another profit center for recovery capitalists have become exactly that.

We are at our best when we are grounded in strong ethical values and focused on community grounded service and at our worst when our systems are oriented towards short-term financial incentives for a few while gatekeeping out broader community-oriented healing strategies, which is the trend now. In consideration, we need to balance the interests of profit oriented industry with community grounded service values. As often happens when I think I have had an original thought I stumble upon this, that William White wrote in 2002:

“Addiction counseling in the modern era has been practiced as an essentially clinical activity, but this has not always been the case. There have been key points in the history of addiction treatment when the functions of community organization and social activism competed with, or complemented, this clinical orientation… It is argued that the professionalization (medicalization and psychologization) of addiction treatment needs to be balanced by a re-emphasis on recovery as a connection with indigenous resources and relationships beyond the self.”

The New Recovery Advocacy Movement was born a generation ago through grassroots efforts of community members, and much of their vision on what we could achieve has been lost. Without a community grounded vision, it is devolving into just another industry oriented on narrow goals. Are we facing a collapse or at minimum a significant retraction of our efforts as we lose our way? We should ask ourselves:

• What are the organizing concepts in respect to addiction care and recovery support that are broadly agreed upon by all stakeholder groups and community members in our own era?
• What efforts are we initiating to strengthen ethical conduct standards not just on the individual level but across all our related institutions?
• How much of what is occurring now authentically involves the recovery community in all of its diversity?
• Where are our states people that help drive these efforts forward?

What do we want to have written down about our own era of history 25 years from now, and what are we doing to make sure that is the version that unfolds?

Sources

Stauffer, W. (2023, August 19). Social Movements End – So How Will Ours End? Recovery Review. https://recoveryreview.blog/2023/08/19/social-movements-end-so-how-will-ours-end/

Stauffer, W. (2024, April 13). Addiction & Recovery Capitalist – Hustlers Hawking Drugs, Hucksters Selling Recovery. Recovery Review. https://recoveryreview.blog/2024/04/13/addiction-recovery-capitalist-hustlers-hawking-drugs-hucksters-selling-recovery/

Stauffer, W. (2024, September 8). The Devolution of PRSS and the Lost Lessons of Earlier Eras. Recovery Review. https://recoveryreview.blog/2024/09/08/the-devolution-of-prss-and-the-lost-lessons-of-earlier-eras/

Weiner B, White W. The Journal of Inebriety (1876-1914): history, topical analysis, and photographic images. Addiction. 2007 Jan;102(1):15-23. doi: 10.1111/j.1360-0443.2006.01680.x. PMID: 17207119. https://pubmed.ncbi.nlm.nih.gov/17207119/

White, W. (1999). Addiction treatment: Gone yesterday, gone tomorrow? Behavioral Health Management, 19(5), 40-44. https://www.chestnut.org/resources/b0cd23a2-445f-4984-a94f-2aabca4dc09c/1999-Collapse-of-19th-Century-Addiction-Treatment.pdf

White, W. (2002) A lost vision: Addiction counseling as community. Alcoholism Treatment Quarterly 19(4):1-32. https://www.chestnut.org/resources/7fc7b173-9676-4439-8b74-e70f9df18832/2002AddictionCounselingasCommunityOrganization.pdf