Michael M. Miller, MD, FASAM, FAPA History of Addiction Treatment [email protected] in North America And the History of Addiction Medicine Medical Director, Herrington Recovery Center Rogers Memorial Hospital, Oconomowoc, Wisconsin Past President and Board Chair Executive Committee, Public Policy Committee Michael M. Miller, MD, FASAM, FAPA American Society of Addiction Medicine Past President, ASAM Director Medical Director American Board of Addiction Medicine and The ABAM Foundation Herrington Recovery Center, Rogers Memorial Hospital Clinical Adjunct Professor University of Wisconsin School of Medicine and Public Health Assistant Clinical Professor Medical College of Wisconsin, Dept of Psychiatry & Behavioral Health ASAM Disclosure of Relevant Financial Relationships ASAM Review Course 2014 Addiction Treatment in the U.S. Name Commercial Interests Relevant Financial Relevant Financial Relationships: Relationships: What Was Received For What Role • “The Minnesota Model” Michael M. Miller, MD Rogers Memorial Hospital Salary Primary professional position • Hazelden Foundation Honorarium Speakers Bureau training • Willmar State Hospital Alkermes • Miller MM. “Treatment of Addiction: A Clinical Overview." Braeburn Consulting Fee Advisory Board Member Pharmaceuticals, Inc. In Principles of Addiction Medicine, First Edition, 1994 Orexo Honorarium Speakers Bureau training (ASAM) • Miller MM. “Traditional Approaches to the Treatment of Curry Rockefeller Group Consulting Fee Advice re: educational materials to patients Addiction." In Principles…, Second Edition, 1998. BioDelivery Sciences Honorarium Speakers Bureau training Leavitt Partners Honorarium Advice re: population health & prevention approaches to • Addiction Treatment in the U.S. is often caricatured as substance use and addiction nothing other than that One Reference Everyone Cites Outline 1. How do we conceptualize what we’re treating? “Slaying the Dragon” 2. Early treatment approaches in America The History of Addiction Treatment and 3. AA (but it is not treatment) Recovery in America 4. Hazelden and the Minnesota Model 5. Treatment Programs –East Coast, SE, Midwest 6. Treatment Programs –West Coast, et al. William L. White 7. General Musings about Addiction Treatment –so, Bloomington, IL: Chestnut Health Systems. 1998 what is Addiction Treatment anyway? 1 Outline Addiction How the Condition is Conceptualized 8. History of Addiction Treatment Research • The signatory of the U.S. Declaration of 9. History of Addiction Policy and Advocacy Independence, Dr. Benjamin Rush, had described 10. History of Addiction Medicine the “alcoholic disease syndrome” in 1779 (Li, 11. Broadening the Base of Treatment Hewitt, Grant, 2007). 12. Pharmacotherapy • 13. Treatment Criteria The two terms most frequently used to refer to 14. Chronic Disease Management alcoholism at the end of the nineteenth century 15. Contemporary Addiction Treatment were dipsomania and inebriety (White, 2004), 16. Living History as it Happens with both referring to the behaviors of excessive drinking and intoxication. The Journal of Inebriety Weiner, B., & White, W. The Journal of Inebriety (1876–1914): history, topical analysis, and photographic images. Addiction, 102 (1): 15‐23, 2007. Addiction: Addiction How the Condition is Conceptualized How the Condition is Conceptualized • The term “addiction to alcohol” appears to have first been used in the German medical literature in 1901 (Bonhoeffer, 1901; Blakemore, Jennett, 2001), but it became established enough that the National Conference on • Alcoholism is one thing Nomenclature of Disease, the 1933 American process that had inspired the International Classification of Disease (the latest edition, from • Drug Addiction is another 1992, is ICD‐9), had a diagnostic code for "alcohol addiction (code 000‐ 332)” (Keller, 1976). • Jellinek himself (Jellinek, 1942) referred to “alcohol addiction” (Robinson, 1972) for almost two decades prior to the publication of his best known work, The Disease Concept of Alcoholism (Jellinek, 1960). He also described phases of alcohol addiction in an attempt to capture the heterogeneity in manifestations of the disease (Jellinek, 1952). 2 WHO Expert Committee on Mental Health, The Broader Context Alcoholism Subcommittee (1st Report, 1950) “Alcoholism: any form of drinking which in its • The American Medical Society on Alcoholism extent goes beyond the traditional and and Other Drug Dependencies customary ‘dietary’ use, or the ordinary • Alcohol vs. Drugs compliance with the social drinking customs of the whole community concerned, irrespective • Alcoholics Anonymous of the etiological factors leading to such • Narcotics Anonymous behavior….” • Alcohol, Nicotine, and Other Drugs WHO Technical Report Series No. 42, December 1950, pg 5 WHO Expert Committee on Mental Health, WHO Expert Committee on Mental Health, Alcoholism Subcommittee (2nd Report, 1952) Alcoholism Subcommittee (2nd Report, 1952) “The subcommittee has distinguished two “The subcommittee would now consider it categories of alcoholics, ‘alcohol addicts’ and more appropriate to use the preceding ‘habitual symptomatic excessive drinkers’. For definition to define the term ‘excessive brevity’s sake the latter will be referred to as non‐addictive alcoholics. In both groups, the drinking’ and would add to it the excessive drinking is symptomatic of underlying following definition of alcoholism:” psychological or social pathology….” WHO Technical Report Series No. 48, August 1952, pg 16 WHO Technical Report Series No. 48, August 1952, pp. 26‐27 WHO Expert Committee on Mental Health, WHO Expert Committee on Alcoholism Subcommittee (2nd Report, 1952) Drugs Liable to Produce Addiction “…but in one group after several years of “Drug addiction is a state of periodic or excessive drinking ‘loss of control’ over the chronic intoxication, detrimental to the alcohol intake occurs, while in the other individual and to society, produced by the group this phenomenon never develops. The group with ‘loss of control’ is designated repeated consumption of a drug (natural as ‘alcohol addicts’.” or synthetic). Its character‐istics include: (1) an overpowering desire or need (compulsion) to continue taking the drug WHO Technical Report Series No. 48, August 1952, pp 26‐27 and to obtain it by any means 3 WHO Expert Committee on WHO Expert Committee on Mental Health, Drugs Liable to Produce Addiction Alcoholism Subcommittee (1st Report, 1950) “(2)a tendency to increase the dose; “…the Subcommittee recommends that (3) a psychic (psychological) and sometimes a consideration should be given to the physical dependence on the effects of the setting‐up of a subcommittee on Alcohol drug.” of the Expert Committee on Drugs Liable to Produce Addiction.” WHO Technical Report Series No. 21, 1950 WHO Technical Report Series No. 42, December 1950, pg 6 The Definition of Alcoholism What is Addiction? (NCADD / ASAM – 1990, JAMA 1992: Morse et al.) American Society of Addiction Medicine • April 2011 Alcoholism is a primary, chronic disease with genetic, Definition of Addiction: psychosocial, and environmental factors influencing its “Addiction is a primary, chronic disease of brain reward, development and manifestations. The disease is often motivation, memory and related circuitry. Dysfunction in progressive and fatal. It is characterized by continuous these circuits leads to characteristic biological, or periodic: impaired control over drinking, psychological, social and spiritual manifestations. This is preoccupation with the drug alcohol, use of alcohol reflected in an individual pathologically pursuing reward despite adverse consequences, and distortions in and/or relief by substance use and other behaviors.” thinking, most notably denial. Definition of Addiction Models for Understanding Addiction American Society of Addiction Medicine • April 2011 Joseph Westermeyer, MD, PhD, MPH “Addiction is characterized by inability to consistently Moral Model, Criminal Model, Epidemic Model, Illness Model, Personality Disorder Model, Learning Model, Self‐treatment Model, Genetic Model, abstain, impairment in behavioral control, craving, et al. diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a The Illness Model: dysfunctional emotional response.Like other chronic “This model evolved over two centuries ago when addicted persons were diseases, addiction often involves cycles of relapse and unable to cease addictive use of psychoactive substances on their own.” remission. Without treatment or engagement in recovery activities, addiction is progressive and can Westermeyer J. “Chapter 1: Historical Understandings of Addiction.” In: result in disability or premature death.” Principles of Addiction (Peter M. Miller, ed.). Elsevier (2013), page 4. 4 Models for Understanding Addiction Joseph Westermeyer, MD, PhD, MPH Responses to Addiction “First, the addicted person must view him‐ or her‐self as a blighted • The Washingtonians – 1840‐1845 or diseased person in need of outside help. This step, involving illness behavior, occurs after a period of misery and dysfunction. • The Washingtonian Total Abstinence Society Second, those around the person must be willing to deed the person • “The Washingtonian program of recovery consisted of (1) a period of relief from ordinary social expectations and responsibilities, in order to permit treatment and recovery. This public confession, (2) public commitment, (3) visits from involved social assignment of a temporary sick