Outpatient addiction treatment is not a new concept. In fact, the history of outpatient addiction treatment goes back more than 150 years. This makes sense given that psychoactive drugs have been used in some form starting as early as human civilizations began to emerge. Despite thousands of years of experimentation with the substances, it wasn’t until the 17th century that substance abuse became recognized as a societal problem.
Of course, back then, religious beliefs superseded science and so early attempts to defeat addiction were mostly unsuccessful. More organized forms of addiction treatment started with the formation of alcoholic “mutual aid societies” and “sobriety circles” to address addiction and these took rook from around 1750 to early into the 1800s. At the time, these groups were originally comprised of various Native American tribes, Given their introduction to alcohol without any warnings of the potential outcomes, Native Americans suffered from addiction at high rates. Without any scientific community to address addiction, most tribes used native healing practices to treat alcoholism.
Around 1784, a man named Benjamin Rush argued that alcoholism is a disease that should be treated. Rush, a physician committed to educating the public about the dangers of alcohol, argued further that abuse of alcohol was a major public health problem. He wrote many books that helped to spread awareness of the issue.
The evolution of addiction treatment, from the mid-18th century to the present, is outlined below. Several pioneers of treatment during these times contributed to a rich body of scientific knowledge that continues to influence our understanding of addiction today.
The First Rehab Programs (circa 1850)
Rehab first took shape with the advent of Lodging Homes and Homes for the Fallen. They provided short, voluntary stays that included non-medical detoxification, isolation from the drinking culture, moral retraining, and introduction into new (for the time) sobriety fellowships. These first homes, dubbed “inebriate homes”, opened around 1850 starting initially in Boston. Interestingly, they used treatments that were modeled after insane asylums.
New York State followed suit when they opened their first Inebriate Asylum in 1864. Run under the direction of Dr. Joseph Edward Turner, this new approach was the first to medically monitor addiction treatment and is considered to be the first alcohol rehab center.
Around 1870, Dr. Leslie Keeley opened more than 120 addiction treatment facilities throughout North America and Europe. A bit of a snake oil salesman, he also sold some proprietary home cures such as his infamous “Double Chloride of Gold Cures for drunkenness.”
By the 1880s, well known psychiatrist Dr. Sigmund Freud recommended cocaine to treat alcoholism and morphine addiction – clearly the science back then was inferior to the science of today. As you can imagine, this traded one problem for another. Despite that, Sigmund Freud began using cocaine himself, calling it a “magical drug.” It almost killed him, but not before Freud and other American physicians used cocaine to treat alcoholism and morphine addiction for thousands of patients. Later in life, Freud’s backed off his former defense of using cocaine to treat morphine addiction.
So what happened to the Inebriate homes and asylums? They all closed and alcoholics would be sent to drunk tanks, wards, and foul wards of hospitals for the next several decades. Their demise came about because poorly evaluated clinical therapies that had little success and no science-backed research. Ethical abuse, economic depressions, the hateful stigma towards addicts and criminalization of alcohol/drug problems doomed them.
From then on, alcoholics are sent to city drunk tanks, public hospitals, and insane asylums.
Outpatient Addiction Treatment Takes on a New Form (circa 1901 – 1950s)
In 1901, the Charles B. Towns Hospital opens. A collaboration with Dr. Alexander Lambert (Theodore Roosevelt’s personal physician), this facility opened its doors in New York City as a substance abuse hospital to help treat rich and famous alcoholics. with another snake oil dubbed “Belladonna Elixir” A potent mix of Phenobarbital and Vitamin B, you can imagine the outcomes. By the way, Bill Wilson, the founder of Alcoholics Anonymous, was a patient at Charles B. Towns Hospital four times. At a price of $350 a day, equivalent to $5,610 today,it was no bargain.
Around 1906, the Emmanuel Clinic in Boston begins its version of alcohol treatment of alcoholism. This church-based form of therapy consisted of religious psychotherapy along with a combination of spirituality and psychological interventions. This laid the groundwork for the establishment of Alcoholics Anonymous.
Also around this time, things got really interesting as new state laws started to call for the sterilization of the mentally ill, developmentally disabled, and alcoholics and addicts. One cannot even begin to imagine the outrage that would spark in today’s modern society. It gets worse – the medical supervisors of asylums and prisons were granted full the authority to “asexualize” a patient or inmate if this action was, in the view of the medical supervisor, likely to improve the patient’s physical, mental, or “moral” condition. This action speaks to how addicts were considered degenerate and feeble-minded.
Morphine maintenance clinics were created during this time, around 1919 to 1924, to treat people with morphine addiction, but they close eventually, mostly due to legal reasons.
Narcotics farms open (1935). The first federal narcotics farm opened in Lexington, Kentucky in 1935.2 Lexington was a center for drug treatment and federal research, and provided free treatment to addicts and alcoholics, including the “Lexington Cure.” The Narco farm was a prison where research on human subjects could be conducted.12
Alcoholics Anonymous formed (1935). The 4 founding members of Alcoholics Anonymous (AA), Bill Wilson, Ebby Thatcher, Rowland Hazard, and Dr. Bob Smith, were highly influenced by the pioneers of the Emmanuel Movement.10 Wilson and Dr. Bob were both alcoholics in the 1930s, unable to achieve sustained abstinence despite their Christian faith and membership in the Oxford Group, a Christian organization whose principles heavily influenced the creation of the 12 steps.
Modern Addiction & Outpatient Addiction Treatment Evolves (1960s to today)
Many advances have been made as outpatient treatment began to take shape over the last 50 years. Here are some of the highlights during this period:
- AA membership surpasses 90,000 by the mid 1950s. The reach of AA membership grew exponentially, and in 1951, AA’s success is attributed to several factors, including an increase in alcoholism-related films and a wider acceptance of those suffering from the illness.
- The American Medical Association officially defines alcoholism. Eventually, the committee defines it as a primary, chronic disease with genetic, psychosocial, and environmental factors influencing the condition’s prognosis.
- The Veterans Administration establishes alcoholism treatment units as far back as 1957 or so, largely in deference to WWII veterans who were dealing with PTSD before PTSD had ever been established as a real disorder.
- The Halfway House Association founded around 1958. Halfway houses were designed to provide safe, recovery-focused housing for individuals who were suffering from substance abuse problems.
- E.M. Jellinek publishes the The Disease Concept of Alcoholism in 1960.
- The health insurance industry begins to reimburse treatment of alcoholism starting as early as 1964. When the medical community emphasized alcoholism as a chronic disease, policymakers responded, and this lead to an increase in inpatient rehabs as well as the emergence of medication for alcoholism/addiction. In turn, the insurance industry began reimbursing alcoholism treatment as it would for any other disease or ailment.
- In 1964, Methadone was introduced. Vincent Dole, an endocrinologist, and Dr. Marie Nyswander, a psychiatrist, developed methadone as a means to treat narcotic addiction. The FDA approved it to treat heroin addiction in 1972. Since then, Methadone has proven to be effective as anagonist that prevents harsh opioid withdrawal symptoms
- In 1970, the Lincoln Recovery Center began using acupuncture to treat addiction. Although the Lincoln Recovery was initially an outpatient treatment center that used methadone, through 1973-74, there was a popular, community-based swell that sought natural, non-pharmaceutical treatments for heroin and opioid addiction. This movement towards more “natural” healing spurred the use of acupuncture in the clinic. The alternative treatment proved to be highly successful, and many of the founding staff went on to study acupuncture
- In 1970, the landmark “Controlled Substances Act” passes. The CSA placed all regulated substances into five schedules, or classifications, based on the substance’s medical use, potential for abuse, and dependence liability. Most laws and treatment plans today are built around these classifications.
- In 1971, the FDA approves Narcan to help counter opioid overdose effects. Highly effective, it usually works within 2 minutes. It was first made available as an injectable solution, but is now available as a nasal spray. It has helped to save the lives of hundreds of thousands of people.
- The famous Betty Ford Clinic was founded in 1982. Former First Lady Betty Ford sought treatment for alcohol and prescription pill addiction at age 60 and her plight motivated the development of the first Betty Ford Center in Rancho Mirage, CA.
- In 1982, Cocaine Anonymous was founded. They adopted the 12-step philosophy embraced by Alcoholics Anonymous.
As treatment options developed both medically and clinically, they largely focused around faith-based, counseling-based and medicinal research to help manage and treat patients at every step of the recovery process.
Landmark developments of the last 20 years include the following:
- In 2002, the FDA approved buprenorphine for clinical use. FDA approved buprenorphine, is a medication-assisted treatment (MAT) for opioid addiction. Unlike methadone, which is dispensed within a structured clinic, specially qualified physicians can prescribe buprenorphine.
- The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 is passed. This act requires insurance companies and group health plans to provide similar benefits for mental health and/or substance use treatment and services as other types of medical care.
- The Affordable Care Act (ACA) expanded coverage for addiction treatment in 2010. The ACA expanded the existing MHPAEA’s criteria by making sure insurance plans offered through state health insurance marketplaces included behavioral health services, including substance abuse treatment.
As of 2018, outpatient addiction treatment centers around people who have gone through medical detox or rehab. Getting clean is the first step, following by counseling to help understand and deal with the root causes of addiction. Co-occurring disorders, mental health issues, physical disabilities and trauma are all dealt with during a proper outpatient addiction treatment program. Since addiction can last for years, recovery is not something that happens overnight.
Thankfully, outpatient addiction treatment has come a long, long way from the days of questionable elixirs and institutionalization.
If you or someone you know is suffering from addiction, get help now, even if it’s not with us.